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NLU Content

Content available as of NLU version 3.98

This article lists the clinical notifications, opportunities, and physician messages (herein all referred to as "rules") for 3M™ M*Modal Engage One™, 3M™ 360 Encompass™, and 3M™ M*Modal CDI Collaborate products. Please use the search pane on the left to directly search content, or drill down by Category and Condition below.

The rules are listed by Categories, which align with the Major Diagnostic Categories (MDC), and more specific Conditions within each Category. For each Condition listed, a Rules table lists the following information for each rule:

Each Condition may also include an Evidence table, which contains examples of the supporting evidence for the Condition's rules. Each supporting evidence example may not apply to every rule in that Condition group. If the evidences differ between products, that is noted by the Product column.

Print Options: Use the following print and download buttons to render the content by product in a print-friendly format.




Conditions and Categories

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
150022 Documentation of intracranial mass effect, elevated ICP, or midline shift (+/- clinical, medication, or treatment evidence of elevated ICP) without documentation of etiology of elevated ICP INCREASED INTRACRANIAL PRESSURE

There is documentation of mass effect, increased intracranial pressure, or midline shift of brain. Please document the etiology of this indicator, if known.
 
51000222 Documentation of cerebral edema in a radiology report without provider documentation of cerebral edema The radiology report contains documentation of cerebral edema. Please confirm the diagnosis.  
51000842 Radiologic evidence of midline shift or mass effect and treatment evidence of elevated ICP without documentation of midline shift or mass effect The radiology report contains documentation of mass effect and/or midline shift and there is evidence of treatment for elevated ICP. Please confirm these findings as appropriate.        


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
40901 Documentation of cerebral palsy without documentation of the type of cerebral palsy CEREBRAL PALSY

Please document the type of cerebral palsy.


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
150001 Documentation of stroke and a paresis or plegia (+/- clinical evidence of stroke) without documentation of dominant or nondominant PARAPLEGIA/PARESIS

Please document the side affected by the -plegia or -paresis (e.g., dominant, non-dominant).
   
150002   Documentation of stroke and unresponsiveness (+/- clinical evidence of stroke) without documentation of the level of unresponsiveness (stupor, coma, or locked-in syndrome)  
150004 Documentation of stroke (+/- evidence of the type of stroke) without documentation of the type of stroke STROKE TYPE

Please document the type of cerebral ischemia or infarction (e.g., hemorrhagic, thrombotic, embolic).
150005 Documentation of stroke (+/- clinical evidence of stroke) without documentation of the presence or absence of residual hemiparesis STROKE: RESIDUAL HEMIPARESIS

There is documentation of stroke. Please document whether the patient has any associated physical manifestations.
   
150007 Documentation of brain hemorrhage (+/- clinical evidence of brain hemorrhage) without documentation of the type of brain hemorrhage BRAIN HEMORRHAGE

Please document the type of brain hemorrhage (e.g., intracerebral, nontraumatic, spontaneous, subarachnoid, subdural).
150013 Documentation of stroke (+/- clinical evidence of stroke) without documentation of sequela of stroke STROKE SEQUELAE

Please specify any sequelae of stroke.
 
150014 Documentation of stroke (+/- clinical evidence of stroke) without documentation of the site of stroke STROKE SITE

Please document the site of cerebral ischemia or infarction, if known.
   
150026A Documentation of stroke or a history of stroke and documentation of a behavioral disturbance without documentation of vascular dementia or the etiology of the behavioral disturbance (age: > 18 years) STROKE - BEHAVIORAL DISTURBANCE

There is documentation of stroke and behavioral disturbances. Please clarify whether these are causally related.
   
150027*     Notification: Documentation of stroke, paresis or plegia, and decubitus ulcer        
Cerebrovascular-001 Explicit mention of acute stroke with NIHSS score and presence or absence of coma ACUTE STROKE

Acute stroke has been documented; please document NIHSS score and presence or absence of coma, if possible.
     

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:

Arteriosclerosis

Atrial fibrillation

Bradyarrhythmia

Hemiparesis

Hemiplegia

Hypercholesterolemia

Hypertension

Intracranial hemorrhage

Monoparesis

Monoplegia

Stroke



Clinical signs and symptoms:

Aphasia

Apraxia

Brow ptosis

Gait abnormality

Headache

Loss of consciousness

Muscle tone : dysarthria, flaccidity, hyporeflexia, spasticity, weakness

Numbness

Photophobia

Unresponsiveness

Vertigo



Medication and/or therapeutic treatments:

Anticoagulant reversal therapy

Coagulation factor replacement

Fresh frozen plasma

Vitamin K


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
OtherNervous-002 Evidence of Glasgow coma score < 9 (+/- clinical evidence of coma) without documentation of coma LOW GCS

There is documentation of Glasgow coma score <9. Please document any diagnosis resulting from this indicator.
 


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
150011 Documentation of closed head injury or traumatic brain injury without documentation of concussion HEAD INJURY

There is documentation of closed head injury. Please document any associated diagnosis.
150018 Documentation of loss of consciousness without documentation of the duration of loss of consciousness LOSS OF CONSCIOUSNESS

Please document the duration of LOC, if known.
150019 Documentation of concussion (+/- evidence of duration of loss of consciousness) without documentation of visit type (initial, subsequent, or sequela) CONCUSSION

There is documentation of concussion. Please specify visit type (e.g., initial, subsequent or sequela).
 
150020 Documentation of concussion and loss of consciousness without documentation of the duration of loss of consciousness CONCUSSION WITH LOC

Please document the duration of LOC associated with the concussion, if known.
     
OtherNervous-001 Documentation of concussion without documentation of the presence or absence of loss of consciousness CONCUSSION - B

Please document whether or not there was loss of consciousness associated with the concussion.
       

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Concussion
Intracranial hemorrhage
Traumatic brain injury (TBI)

Clinical signs and symptoms:
Loss of consciousness


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
57001 Documentation of encephalopathy (+/- clinical or lab evidence of encephalopathy) without documentation of the type or etiology of encephalopathy (age: > 18 years) ENCEPHALOPATHY - TYPE

Please document the type or etiology of encephalopathy.
57002 Documentation of encephalopathy and clinical evidence of coma (+/- clinical, lab, or substance evidence of encephalopathy) without documentation of coma ENCEPHALOPATHY

There is documentation and clinical evidence of encephalopathy and evidence of decreased responsiveness. Please document any associated diagnosis.
57004 Documentation of altered mental status or confusion without documentation of the presence or absence of encephalopathy Altered mental status or confusion have been documented. Please confirm the presence or absence of encephalopathy.
57005 Documentation of altered mental status and clinical or medication evidence of metabolic encephalopathy or clinical, lab, or medication evidence of encephalopathy without documentation of metabolic encephalopathy ALTERED MENTAL STATUS - C

There is evidence of a neurological disorder, please fully document the type of neurological disorder, if known.
     
Encephalopathy-001 Documentation of encephalopathy without documentation of clinical, lab, or substance evidence of encephalopathy and documentation of type or etiology of encephalopathy ENCEPHALOPATHY TYPE AND EVIDENCE

Please specify the type and include the clinical indicators supporting the diagnosis of encephalopathy.

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Alcoholism
Altered Mental Status
Encephalitis
Hypercapnia
Hypoglycemia
Hyponatremia
Hypoxia
Leigh's disease
Neuro-Whipple's disease
Respiratory failure
Sepsis
Uremia
Vitamin B deficiency: cobalamin, niacin, thiamin

Clinical signs and symptoms:
Confusion
Exposure: organic chemical solvent
Unresponsiveness

Labs:
Ammonia level : >=124 mmol/L
Blood gases:
Partial pressure of carbon dioxide (pCO2) : arterial or venous >45 mmHg
Partial pressure of oxygen (pO2) : <60 mmHg
Blood glucose : <50 mg/dL
Blood oxygen saturation (O2) : <90%
Glomerular filtration rate (GFR) : <15ml/min
Thiamine : <2.5 mcg/dL
Vitamin B12 : <200 pg/mL

Medications and/or therapeutic treatments:
Antimicrobials

Diagnostic procedures and/or procedure findings:
Electroencephalogram (EEG) : abnormal
Glasgow coma score : total <9

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12012P 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.
 


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
150008 Documentation of hydrocephalus without documentation of the type of hydrocephalus HYDROCEPHALUS

Please specify the type of hydrocephalus, if known.
 
150009 Documentation of ventriculoperitoneal shunt without documentation of hydrocephalus VP SHUNT

There is documentation of VP (ventricular peritoneal) shunt. Please document the underlying condition.
 
150017*     Notification: Documentation of ventriculoperitoneal shunt        

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnostic procedures and/or procedure findings:
Cerebral ventricular distension
Cerebral ventriculomegaly
Hydrocephalus
Ventricular peritoneal (VP) shunt

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
Metastatic-001 Documentation of brain tumor without documentation of brain metastasis BRAIN TUMOR

Brain tumor was documented. Please document the brain metastatic disease, if known.
   


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
150006 Documentation of ataxia without documentation of type of ataxia ATAXIA

Please document the type of ataxia.
 
150010 Documentation of aphasia without documentation of the type of aphasia APHASIA

Please document the type of aphasia.
     
150012 Documentation of seizure without documentation of type of seizure SEIZURE

Please document the type of seizure.
150016*     Notification: Documentation of weakness, hemiparesis, or hemiplegia        
150021 Documentation of dysarthria or anarthria without documentation of the etiology of dysarthria or anarthria DYSARTHRIA/ANARTHRIA

Please document the etiology of dysarthria or anarthria, if known.
     
150023 Documentation of EMG or nerve conduction study without documentation of limb with laterality EMG

Please document the anatomic site of the EMG/nerve conduction study.
       
150024 Documentation of weakness without documentation of the laterality of weakness WEAKNESS

Please document site and laterality of weakness.
   
150028 Documentation of family history of Huntington's disease, or abnormal findings of the basal ganglia, or clinical evidence of Huntington's disease without documentation of the presence or absence of Huntington's disease There is evidence of Huntington's Disease, if true please specify.  
43006 Documentation of diabetes and a neuropathic agent without documentation of diabetic peripheral neuropathy DIABETES - NEUROPATHIC AGENTS

There is documentation of diabetes and a neuropathic agent. Please document any associated diagnosis.
     
OtherNervous-003 Documentation of seizure (+/- clinical evidence or family history of seizure) without documentation of the type of seizure SEIZURE - B

Please document the type of seizure.

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Aphasia
Brain disorder: cerebral edema, cerebral herniation, cerebral ventriculomegaly, congenital
Dysarthria
Dysphagia
Inflammatory disease of central nervous system
Seizure (include family history)
Stroke
Substance dependence
Traumatic brain injury (TBI)

Clinical signs and symptoms:
Altered mental status
Diplopia
Elevated temperature : >104.4 Fahrenheit or 40 Celsius
Elevated intracranial pressure
Headache
Lethargy
Speech disturbance
Unresponsiveness
Vomiting
Weakness: limb, muscle, partial/complete body

Medications and/or therapeutic treatments:
Craniectomy
Osmotic diuretic
Phenobarbital
Sodium chloride
Ventilator support
Ventriculostomy

Diagnostic procedures and/or procedure findings:
Cerebral drain
Computed tomography (CT): brain, head, neck
Electromyography (EMG)
Glasgow coma score: total <9
Intracranial evacuation
Magnetic resonance imaging (MRI): brain, head, neck
Nerve conduction study

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
41001 Documentation of spina bifida without documentation of the affected spinal segment SPINA BIFIDA

Please document the spinal level of spina bifida.
   
41002 Documentation of spina bifida without documentation of presence or absence of hydrocephalus SPINA BIFIDA - B

Please document any condition(s) associated with spina bifida.
   

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Meningocele


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
150025 Documentation of transient ischemic attack (+/- history of stroke or evidence of the etiology of TIA) without documentation of the etiology of transient ischemic attack TRANSIENT ISCHEMIC ATTACK

Please document the etiology of TIA, if known.
     

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
44001P Pediatric: Documentation of cleft palate without documentation of site Please document the site of cleft palate.        
44002P Pediatric: Documentation of cleft lip without documentation of laterality Please document the site of cleft lip.        


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
60301 Documentation of head and/or neck cancer without documentation of the specific site of the cancer HEAD/NECK CANCER

Please document the site of the head/neck cancer.
 


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
50205 Documentation of mastoiditis (+/- clinical evidence of mastoiditis) without documentation of the acuity of mastoiditis MASTOIDITIS

Please document the acuity of mastoiditis.
     

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Mastoiditis

Clinical signs and symptoms:
Erythema
Fever
Headache
Hearing loss
Otorrhea
Pain: ear, mastoid
Swelling

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
40101P Pediatric: Documentation of bronchiolitis without documentation of the causative organism of bronchiolitis Please document the causative organism for acute bronchiolitis, if known.      
40102P Pediatric: Documentation of RSV without documentation of RSV bronchiolitis or pneumonia There is documentation of RSV. Please document any associated diagnosis.  


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12008 Documentation of pleural effusion (+/- clinical evidence of pleural effusion) without documentation of the type of pleural effusion PLEURAL EFFUSION

Please document the type of pleural effusion.
   
12022 Documentation of pulmonary edema (+/- clinical evidence of pulmonary edema) without documentation of the acuity of pulmonary edema PULMONARY EDEMA

Please document the acuity of the pulmonary edema.
 


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
32000 Documentation of asthma (+/- clinical evidence of asthma exacerbation or documentation of asthma medication) without documentation of the severity and acuity of asthma ASTHMA

Please specify **severity** (mild, moderate, severe, brittle) and **acuity** (acute vs chronic).
   
32001 Documentation of asthma (+/- clinical or medication evidence of asthma) without documentation of type of asthma ASTHMA - TYPE

Please document the type of asthma.
   
46003 Documentation of asthma and documentation of asthma medication or clinical evidence of asthma without of documentation of acute exacerbation or status asthmaticus ASTHMA - INDICATORS/TREATMENT

There is documentation of asthma and respiratory rate >30. Please document any associated diagnosis.
   
46004 Documentation of asthma without documentation of severity of asthma ASTHMA - SEVERITY

Please document the severity of asthma.
   
46005 Documentation of mild asthma without documentation of persistence of asthma ASTHMA - PERSISTENCE

There is documentation of mild asthma. Please specify whether it is intermittent or persistent.
   
46006 Documentation of asthma without documentation of intermittent asthma or severity of persistent asthma and the presence or absence of status asthmaticus, asthma exacerbation or uncomplicated asthma ASTHMA - STATE

Please specify the **severity** (mild, moderate, severe) & persistence (intermittent, persistent) and Acute Exacerbation/Status Asthmaticus of asthma/Uncomplicated asthma
   
Asthma-001 Documentation of asthma (+/- clinical or medication evidence of asthma) without documentation of acuity of asthma ASTHMA - B

Please document the acuity of the asthma.
   

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Asthma

Clinical signs and symptoms:
Chest wall retractions
Dyspnea
Hypoxia
Respiratory distress
Shortness of breath
Tachypnea
Wheezing

Medications and/or therapeutic treatments:
Anticholinergics
Beta-2 agonists
Corticosteroids
Incentive spirometry

Diagnostic procedures and/or procedure findings:
Peak expiratory flow rate

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
PedAsthma-001P 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.    


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
11010 Documentation of COPD and continuous home oxygen use (+/- lab evidence chronic respiratory failure) without documentation of chronic respiratory failure HOME OXYGEN

There is documentation of continuous home oxygen use and COPD. Please document any associated diagnosis.
 
11017 Documentation of COPD and home oxygen use (+/- lab evidence chronic respiratory failure) without documentation of chronic respiratory failure HOME OXYGEN - B

There is documentation of home oxygen use and COPD. Please document any associated diagnosis.
 
11018*     Notification: Documentation of COPD and clinical or medication evidence of COPD exacerbation        
11019 Documentation of acute exacerbation of COPD (+/- documentation of clinical, medication, or vital sign evidence of COPD exacerbation) without documentation of etiology of COPD exacerbation COPD - B

Please document the etiology of the COPD exacerbation.
       
11021   Documentation of home oxygen and chronic respiratory failure and pulmonary fibrosis or COPD (+/- clinical or lab evidences of respiratory failure) without documentation of home oxygen volume      
11022   Documentation of home oxygen use without documentation of associated respiratory disorder        
12009 Documentation of acute bronchitis (+/- clinical evidence of acute bronchitis) without documentation of the etiology of acute bronchitis ACUTE BRONCHITIS

Please document the etiology or causative organism of acute bronchitis.
       
50206 Documentation of bronchitis (+/- clinical evidence of acute bronchitis) without documentation of the acuity of bronchitis BRONCHITIS

Please document the acuity of bronchitis.
   
59001 Documentation of COPD and clinical evidence or respiratory rate >24 (+/- documentation of COPD medications) without documentation of COPD status COPD

There is documentation of COPD and evidence of tachypnea and/or other respiratory signs and symptoms. Please document the COPD status (e.g., acute exacerbation, stable).
   
COPD-001 Documentation of COPD without documentation of COPD status COPD - C

Please document the status of COPD
   

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Chronic obstructive pulmonary disease (COPD)
Chronic lung disease
Congenital lobar emphysema
Cystic fibrosis
Pulmonary fibrosis
Respiratory failure

Clinical signs and symptoms:
Cough
Drowsiness
Dyspnea
Hypoxia
Respiratory distress
Respiratory rate: >=24 breaths/min
Tachycardia
Tachypnea
Wheezing

Labs:
HCO3
pCO2
pH

Medications and/or therapeutic treatments:
Azithromycin
Bronchodilators
Corticosteroids
Home oxygen
Ipratropium
Theophylline
Ventilator support


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
17001 Documentation of transbronchial biopsy without documentation of lung or lung tissue TRANSBRONCHIAL BIOPSY SITE

Please document the site (i.e., tissue or organ structure) of the transbronchial biopsy.
       


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
15018*     Notification: Documentation of COVID-19 or a COVID-19 positive lab (+/- documentation of oxygen therapy, ventilator therapy, COVID-19 symptoms, COVID-19 comorbidities, or COVID-19 risk factors)        
15019*     Notification: Documentation of possible COVID-19 (+/- documentation of oxygen therapy, ventilator therapy, COVID-19 symptoms, COVID-19 comorbidities, or COVID-19 risk factors)        
15020*     There is documentation of COVID-19        
15021*     Identification of possible COVID-19 high risk patients        
15022*     Triaging potential COVID-19 cases        
15023*     Notification: Documentation of a patient discharge and documentation of COVID-19 or a COVID-19 positive lab        
51000549 Documentation of COVID-19 without documentation of whether it is an active or historic diagnosis, and whether there are sequela COVID-19- RULE B

Please document the status of COVID-19 as appropriate.
   
51001103* Documentation of COVID-19 vaccine received DOCUMENATION OF COVID-19 VACCINE RECEIVED

       
COVID-001 Documentation of COVID-19 or a COVID-19 positive lab and documentation of a complication without documentation of whether there is a link between COVID-19 and the complication COVID-19

COVID-19 and a complication were documented, but the link between them was not documented.
       

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
COVID-19

Labs:
SARS coronavirus 2: positive

Clinical signs and symptoms:
Cough
Difficulty breathing
Exposure to SARS coronavirus 2
Fever
Loss of sense of smell

Medications and/or therapeutic treatments:
COVID-19 vaccine

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51000442 Documentation of malignant effusion without documentation of the primary malignancy site MALIGNANT EFFUSION

Please document the primary malignancy site associated with the malignant effusion.
       
60201 Documentation of secondary neoplasm of lung without documentation of laterality LUNG METS LATERALITY

Please document the laterality of the lung affected by metastatic cancer.
       
67001 Documentation of lung cancer without documentation of the laterality and site of the affected lung LUNG CANCER

Please document the site and laterality of lung cancer.
   


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
OtherResp-001*     There is explicit mention of CPAP or BIPAP        


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
15002*     Notification: Documentation of pneumonia (+/- documentation of causative organism of pneumonia or clinical or radiologic evidence of pneumonia)
15003   Documentation of pneumonia and clinical evidence of ventilator (+/- clinical or medication evidence of Gram negative pneumonia) without documentation of ventilator-acquired pneumonia  
15005   Documentation of pneumonia and clinical, medication, or radiologic evidence of aspiration without documentation of aspiration pneumonia  
15006 Documentation of pneumonia (+/- evidence of aspiration, Gram negative, MRSA, or ventilator pneumonia) without documentation of etiology or type of pneumonia PNEUMONIA

Please document the etiology or type of pneumonia, if known
15008*     Notification: Documentation of possible pneumonia (+/- documentation of causative organism of pneumonia or clinical or radiologic evidence of pneumonia)        
15009*     Notification: Documentation that pneumonia was present on admission        
15012 Documentation of radiation or teleradiotherapy procedure and pneumonia or pneumonitis and clinical evidence of pneumonia without documentation of radiation-induced pneumonia PNEUMONIA - TELERADIOTHERAPY

Pneumonia and a teleradiotherapy procedure are documented. Please document type of pneumonia.
 
15013 Documentation of pneumonia without documentation of present on admission status PNEUMONIA POA

Please document whether pneumonia was present on admission.
     
15014 Documentation of healthcare-acquired pneumonia and antibiotics for gram negative pneumonia without documentation of pneumonia caused by Gram negative bacteria HCAP

HCAP and antibiotics for treating HCAP have been documented. Please document the etiology of pneumonia, if known.
 
15015 Documentation of healthcare-acquired pneumonia and vancomycin without documentation of MRSA pneumonia HCAP - VANCOMYCIN

HCAP and Vancomycin have been documented. Please document the etiology of pneumonia, if known.
 
15016*     Notification: Documentation of healthcare- or community-acquired pneumonia        
51000605 Documentation of pneumonia and antibiotic therapy without documentation of the type of pneumonia PNEUMONIA - B

Pneumonia and antibiotic therapy were documented. Please document type of pneumonia, if known.
51001286A Documentation of pneumonia in the emergency department without documentation of pneumonia in the inpatient documentation (age >18 years) Pneumonia is documented in the emergency department but has not been documented after admission. Please clarify the presence or absence of this diagnosis.        
Pneumonia-005 Documentation of pneumonia (+/- causative organism of pneumonia) without clinical evidence of pneumonia PNEUMONIA WITHOUT SUPPORTING EVIDENCE

Pneumonia has been explicitly mentioned. Please document the **evidence** of pneumonia, if possible.
     
Pneumonia-007 Radiologic evidence of pneumonia and administration of antibiotics (+/- clinical evidence of pneumonia) without documentation of the causative organism or type of pneumonia RESPIRATORY DISORDER

There is radiologic evidence of respiratory disease and evidence of antibiotic administration. Please document any associated diagnosis.

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Alcoholism
Bronchiectasis
Chest wall retractions
Chronic obstructive pulmonary disease (COPD)
Cystic fibrosis
Dyspnea
End stage renal disease (ESRD)
Esophagus: obstruction, stricture
Esophagus tumor
Immunosuppression
Long term care: nursing home
Open wound
Pneumonia
Pneumonitis
Pulmonary aspiration
Skin ulcer
Stroke

Clinical signs and symptoms:
Bed-ridden
Breath sounds: abnormal, absent, crackles, crepitation, decreased, rales, rhonchi, squawk
Chest pain
Cough
Difficulty breathing
Dysphagia
Fever
Muscle weakness
Respiratory distress
Vomiting

Labs:
Sputum culture: positive

Medications and/or therapeutic treatments:
Antibiotics
Enteral feeding
Nasogastric (NG) tube
Respiratory support: mechanical ventilation

Diagnostic procedures and/or procedure findings:
Barium swallow study: abnormal
Bronchoalveolar lavage (BAL)
Catheter: central, venous
Lung consolidation
Radiologic infiltrate of lung
Radiation therapy

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001424P 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.        


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
11006*     Notification: Documentation of respiratory failure and post-operative period        
11020*     Notification: Documentation of respiratory failure and post-operative period (+/- documentation of positive smoking history or respiratory diagnoses)        


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
29006 Documentation of pulmonary embolism without documentation of the presence or absence of cor pulmonale or right ventricular strain PULMONARY EMBOLISM

Please document whether or not the pulmonary embolism is associated with cor pulmonale or any other complications.
   
29007 Documentation of pulmonary embolism without documentation of the etiology of pulmonary embolism PULMONARY EMBOLISM - CAUSE

Please document the cause of pulmonary embolism, if known.
   
29013 Documentation of pulmonary embolism without documentation of present on admission status PULMONARY EMBOLUS POA

Please document whether pulmonary embolism was present on admission.
   
50202 Documentation of pulmonary embolism without documentation of the acuity of pulmonary embolism PULMONARY EMBOLISM - ACUITY

Please document the acuity of the pulmonary embolism.
 

Evidence

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Product Evidence
E11 CDI2
Diagnoses:
Pulmonary thrombosis


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
11000 Documentation of respiratory failure (+/- clinical or lab evidence of respiratory failure or documentation of coexisting diagnoses) without documentation of acuity of respiratory failure (age: > 28 days) RESPIRATORY FAILURE

Please document the acuity of the respiratory failure.
11002 Documentation of ventilator, intubation, or noninvasive respiratory support without documentation of respiratory failure RESPIRATORY DISORDER - C

There is evidence of ventilator, intubation, or other respiratory support. Please document any associated diagnosis.
11003 Documentation of respiratory insufficiency without documentation of respiratory failure RESPIRATORY INSUFFICIENCY

The symptom of respiratory insufficiency has been documented. Please document a specific diagnosis.
11004   Documentation of respiratory failure without documentation of the etiology of respiratory failure RESPIRATORY FAILURE - ETIOLOGY

Please document the etiology of the respiratory failure.
       
11005 Documentation of hypoxia and clinical or lab evidence of respiratory failure without documentation of respiratory failure HYPOXIA

There is documentation of hypoxia. Please document any associated diagnosis.
11007*     Notification: Documentation that acute respiratory failure was present on admission        
11012 Documentation of acute respiratory failure without clinical or lab evidence or documentation of coexisting diagnosis ACUTE RESPIRATORY FAILURE

Please include the clinical indicators supporting the diagnosis of acute respiratory failure.
   
11013 Documentation of acute respiratory distress without documentation of acute respiratory failure ACUTE RESPIRATORY DISTRESS

The symptom of acute respiratory distress has been documented. Please document the associated diagnosis.
11014 Documentation of acute respiratory failure without documentation of present on admission status ACUTE RESPIRATORY FAILURE POA

Please document if acute respiratory failure was present on admission.
   
11015 Documentation of respiratory distress or respiratory failure or lab evidence of respiratory failure (+/- clinical evidence of acute or chronic respiratory failure) without documentation of hypoxemic or hypercapnic respiratory failure and acuity RESPIRATORY DISORDER - B

There is documentation or evidence of respiratory failure/distress, please document the **type** and **acuity** of respiratory failure.
 
11016 Documentation of abnormal SpO2/FiO2 or PaO2/FiO2 ratio without documentation of ALI, ARDS, or acute respiratory failure SF/PF RATIO

There is evidence of abnormal P/F and/or S/F ratio. Please document any associated diagnosis.
RespFailure-001 Documentation of hypercapnia without documentation of hypercapnic respiratory failure HYPERCAPNIA

Please document the etiology of the hypercapnia or hypercarbia.

Evidence

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E11 CDI2
Diagnoses:
Acute respiratory distress syndrome (ARDS)

Chronic Lung Disease

Drug overdose

Obesity

Head Injury

Hypercapnia

Hypoxemia

Hypoxia

Myasthenia gravis

Pulmonary embolism

Pulmonary edema

Pulmonary hypertension

Pneumothorax

Respiratory failure

Severe asthma

Tachypnea

Clinical signs and symptoms:
Asterixis

Dyspnea

Chest wall retraction

Cyanosis

Nasal flaring

Stridor

Respiratory rate: > 24 respirations per minute

Tabaco user

Labs:
Arterial HCO3: > 26 mEq/L

Arterial pO2: < 70 % mmHg

Arterial pO2/FiO2 (PF ration): < 200

Carbon dioxide (CO2): > 30 mmol/L

Arterial fraction of inspired oxygen (FiO2): > 32%

Oxygen saturation (SpO2): < 91%

Oxygen saturation SpO2/FiO2 (SF Ration): < 235

Partial pressure of carbon dioxide (pCO2): > 45% mmHg

pH < 7.35


Medications and/or therapeutic treatments:
Respiratory Support


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
PedRespFailure-001P 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.  


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
4000001 Documentation of thoracentesis without documentation of intent and laterality of thoracentesis THORACENTESIS

Please document the laterality and intent of the thoracentesis procedure.
       

Evidence

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Product Evidence
E11 CDI2
Diagnostic procedures and/or procedure findings:
Thoracentesis

Rules

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*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
5004*     Notification: Documentation of hypertension and angina (+/- clinical evidence of angina or evidence of hypertension medication)        
5005*     Notification: Documentation of angina and a social history of smoking (+/- clinical evidence of angina)        
5006   Documentation of chest pain without documentation of the etiology of chest pain CHEST PAIN

Please document the etiology of the chest pain, if known.
 
5012 Documentation of angina (+/- clinical evidence of angina) without documentation of the type of angina ANGINA TYPE

Please document the type of angina.
 


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
7001 Documentation of atrial flutter (+/- clinical evidence of atrial flutter) without documentation of the type of atrial flutter ATRIAL FLUTTER

Please document the type of atrial flutter.
   
7003*     Notification: Documentation of SVT (+/- clinical evidence of SVT)        
7006 Documentation of SVT with sudden onset (+/- clinical evidence of SVT) without documentation of paroxysmal SVT SUPRAVENTRICULAR TACHYCARDIA

Sudden onset was identified with supraventricular tachycardia. Please consider further specifying the condition.
     
7007 Documentation of AV block (+/- clinical or medication evidence of AV block) without documentation of the type of AV block AV BLOCK

Please document the type of AV block.
 
7008*     Notification: Documentation of SA node dysfunction (+/- clinical evidence of SA node dysfunction)        

Evidence

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Product Evidence
E11 CDI2
Diagnoses:
Angina
Cerebrovascular accident (CVA)
Heart failure

Clinical signs and symptoms:
Anxiety
Arrhythmia
Asthenia
Bradycardia
Chest pain
Dizziness
Dyspnea
Dysuria
Fatigue
Hypotension
Irregular heart beat
Palpitations
Shortness of breath
Sweating
Syncope
Tachycardia

Medications and/or therapeutic treatments:
Anti-arrhythmics
Cardiac resynchronization
Pacemaker: implantable, temporary

Diagnostic procedures and/or procedure findings:
Borg breathlessness scale
Cardiac monitoring: 24 hour recording, Holter monitor

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
7000 Documentation of atrial fibrillation (+/- clinical evidence of atrial fibrillation) without documentation of the type of atrial fibrillation ATRIAL FIBRILLATION

Please document the type of atrial fibrillation.
   


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
7009 Documentation of cardiac arrest (+/- clinical evidence of cardiac arrest) without documentation of the etiology of cardiac arrest CARDIAC ARREST ETIOLOGY

Please document the etiology of cardiac arrest, if known.
 


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
7002 Documentation of cardiomyopathy (+/- clinical evidence of cardiomyopathy) without documentation of the type of cardiomyopathy CARDIOMYOPATHY

Please document the type of cardiomyopathy.
 
7011 Documentation of cardiomyopathy (+/- clinical evidence of cardiomyopathy) without documentation of the type of cardiomyopathy and the presence or absence of heart failure CARDIOMYOPATHY - B

Cardiomyopathy type and heart failure presence, absence, or clinically undetermined should both be mentioned.
 

Evidence

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E11 CDI2
Diagnoses:
Angina
Cardiomyopathy

Clinical signs and symptoms:
Atrial fibrillation
Cardiomegaly
Chest pain
Cough
Dyspnea
Edema
Fatigue
Hypervolemia
Hypotension
Orthopnea
Palpitations
Shortness of breath
Supraventricular tachycardia
Syncope
Tachycardia
Weakness

Diagnostic procedures and/or procedure findings:
Left ventricular hypertrophy

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
400001P Pediatric: Documentation of congenital heart disease without documentation of the type of congenital heart disease Please document the type of congenital heart disease.  


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
29004 Documentation of DVT without documentation of the acuity and laterality of DVT DVT

Please document the acuity and laterality of the DVT.
   
29005 Documentation of DVT without documentation of the site of DVT and proximal or distal DVT SITE

Please document the site of the DVT and whether it is proximal or distal.
   
29011 Documentation of DVT without documentation of present on admission status DVT POA

Please document whether DVT was present on admission.
     
29012 Documentation of VTE without documentation of present on admission status VTE POA

Please document whether venous thromboembolism was present on admission.
   


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
10000 Documentation of heart failure (+/- clinical, lab, medication and/or echo evidence of heart failure) without documentation of the type and acuity of heart failure HEART FAILURE - B

Please document the type and acuity of heart failure.
 
10003A   Documentation of acute heart failure without clinical, lab, medication, or radiologic evidence of acute heart failure (age: > 18 years)    
10005A   Documentation of systolic heart failure without clinical, echo, or medication evidence of systolic heart failure (age: > 18 years)  
10006A   Documentation of diastolic heart failure without clinical or echo evidence of diastolic heart failure (age: > 18 years)  
10007*     Notification: Documentation of cor pulmonale (+/- clinical evidence of cor pulmonale)        
10008 Documentation of heart failure without documentation of the type of heart failure HEART FAILURE SPECIFICITY

 
10009 Documentation of cor pulmonale without documentation of the acuity of cor pulmonale COR PULMONALE

Please document the acuity of cor pulmonale.
 
10010 Documentation of heart failure without documentation of the etiology of heart failure HEART FAILURE - ETIOLOGY

Please document the etiology of heart failure, if known.
       
SpecialReqIU-001*     Notification: Documentation of heart failure in the impression or assessment/plan section        


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
18007 Documentation of hypertension and heart failure (+/- clinical or medication evidence of hypertensive heart disease) without documentation of hypertensive heart disease HYPERTENSIVE HEART DISEASE

Hypertension and heart failure were documented, please confirm if hypertensive heart disease is applicable.
 
18012A Documentation of hypertension and female sex (+/- medication evidence of hypertension or documentation of pregnancy) without documentation of the type of hypertension (age: > 18 years) HYPERTENSION TYPE - OBSTETRICS

Please document the type of hypertension.
 
420001P 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

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E11 CDI2
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

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
18000 Documentation of hypertensive urgency, emergency or crisis without documentation of accelerated or malignant hypertension HYPERTENSION

Please document the type of hypertension (e.g., accelerated, malignant, or essential).
     
18004A Documentation of essential hypertension, and clinical or medication evidence of malignant or accelerated hypertension, and clinical evidence of hypertensive urgency, without documentation of benign, malignant or accelerated hypertension (age: > 18 years) HYPERTENSION TYPE

       
18005   Documentation of pre-eclampsia and hypertensive urgency, emergency or crisis without documentation of accelerated or malignant hypertension        
18006*     Notification: Documentation of accelerated or malignant hypertension and medication evidence of an IV or STAT antihypertensive      
18008 Documentation of accelerated or malignant hypertension without documentation of hypertensive urgency, emergency, or crisis HYPERTENSION TYPE - B

Please document the acuity of the hypertensive episode (e.g., urgency, emergency, or crisis).
     
18010A Clinical evidence of hypertensive urgency and medication evidence of an IV or STAT antihypertensive (+/- documentation of hypertension) without documentation of hypertensive urgency, emergency or crisis (age: > 18 years) ELEVATED BLOOD PRESSURE

There is evidence of elevated systolic and/or diastolic blood pressure and antihypertensive medication. Please document any associated diagnosis.
     
18011A Clinical evidence of hypertensive urgency and medication evidence of an IV or STAT antihypertensive (+/- documentation of hypertension) without documentation of hypertensive urgency, emergency, or crisis, pre-eclampsia, eclampsia, or unspecified hypertension (age: > 18 years) ELEVATED BLOOD PRESSURE - B

There is evidence of elevated systolic and/or diastolic blood pressure and antihypertensive medication. Please document any associated diagnosis.
 


Rules

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*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
5000A Documentation or EKG evidence of ACS and lab evidence of ACS (+/- clinical evidence of ACS) without documentation of the type of ACS (age: > 18 years) CARDIAC DISORDER

There is evidence of a cardiac disorder. Please document the corresponding condition and type, if known.
5001 Documentation of MI (+/- clinical, EKG, and/or lab evidence of MI) without documentation of STEMI, NSTEMI, or aborted MI MYOCARDIAL INFARCTION

Please document the type of MI.
5002*     Notification: Documentation of possible ACS (+/- clinical evidence of ACS)        
5003*     Notification: Documentation of possible MI (+/-clinical, EKG, and/or lab evidence of MI)        
5008 Documentation of MI, STEMI, or NSTEMI (+/- clinical evidence of ACS) without documentation of the type of STEMI/NSTEMI MYOCARDIAL INFARCTION - B

Please document the type of myocardial infarction.
5009 Documentation of STEMI (+/- clinical evidence of ACS) without documentation of the STEMI site STEMI

Please document the site of the STEMI.
   
5010A Documentation of Type 2 MI (+/- clinical evidence of ACS) without documentation of the etiology of Type 2 MI (age: > 18 years) MYOCARDIAL INFARCTION ETIOLOGY

Pleasure ensure that the **etiology** of the type 2 STEMI/NSTEMI/MI is documented, if known.
   
5011*     Notification: Documentation of demand ischemia (+/- clinical evidence of ACS)        
51000604 Documentation of elevated troponin (+/- clinical evidence of ACS) without documentation of etiology of elevated troponin There is evidence of elevated troponin. If appropriate, please document the associated diagnosis.        
ACS-001A Documentation of ACS without documentation of the type of ACS (age: > 18 years) ACUTE CORONARY SYNDROME - B

Please document the type of ACS (e.g., angina, STEMI, NSTEMI, aborted MI).
ACS-002 Documentation of demand ischemia without documentation of the etiology of demand ischemia ETIOLOGY OF DEMAND ISCHEMIA

Please document the etiology of demand ischemia, if known.
 
ACS-003 Documentation of NSTEMI without evidence of EKG changes, biomarkers, or clinical evidence of NSTEMI NSTEMI

Please include the clinical indicators supporting the diagnosis of NSTEMI.
   


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12023   Documentation and clinical evidence of limb ischemia (+/- diagnostic tests or conditions associated with limb ischemia, or history of smoking) without documentation of the etiology of limb ischemia ISCHEMIC EXTREMITY

There is evidence or explicit mention of ischemic extremity, please state underlying **etiology** if possible.
   
51001186 Documentation of peripheral vascular disease without documentation of atherosclerosis There is documentation of PVD. Please document any associated diagnosis.  
51001382A Documentation of volume overload (+/- clinical evidence of volume overload) without documentation of etiology of volume overload (age: >18 years) There is documentation of volume overload. Please document etiology of volume overload.        
7004 Documentation of a mitral valve disorder (+/- clinical evidence of a mitral valve disorder) without documentation of mitral insufficiency or prolapse MITRAL VALVE DISORDER

Please document the type of mitral valve disorder.
       
7005 Documentation of a valve disorder (+/- clinical evidence of a valve disorder) without documentation of valve stenosis or valve stenosis with insufficiency VALVE DISORDER

Please document the type of valve disorder.
     
OtherCirc-001 Explicit mention of the etiology of pericardial effusion PERICARDIAL EFFUSION - ETIOLOGY

Please document the etiology of pericardial effusion, if known.
   
OtherCirc-002 Explicit mention of the etiology of aortic valve stenosis AORTIC VALVE STENOSIS - ETIOLOGY

Please document the etiology of aortic valve stenosis, if known.
   
OtherCirc-003 Clinical evidence of endocarditis without documentation of endocarditis and the etiology of endocarditis CARDIAC DISORDER - B

There is evidence or explicit mention of endocarditis. Please document endocarditis and its etiology, if known.

Evidence

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E11 CDI2
Diagnoses:
Atherosclerosis
Arterial stenosis
Cardiac arrest
Diabetes mellitus
Endocarditis
Heart failure
Hypertension
Ischemic limb
Pericardial effusion
Peripheral vascular disease

Clinical signs and symptoms:
Absent pulse
Amputation
Cold limb
Collapse
Diaphoresis
Dizziness
Dyspnea
Edema
Fatigue
Fever
Gangrene
Heart murmur
Intermittent claudication
Loss of consciousness
Low blood pressure
 Children (ages <= 18): age-based values
Necrosis
Night sweats
Non-healing wound
Neuropathy
Orthopnea
Pain: chest, limbs
Palpitations
Petechiae
Shortness of breath
Skin discoloration
Smoking: current, historical
Splenomegaly
Syncope
Weight loss: excessive, unintentional

Diagnostic procedures and/or procedure findings:
Deep venous thrombosis
Doppler/duplex ultrasound
Heart valve disorder

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
430001P Pediatric: Clinical evidence of hypotension without documentation of hypotension There is evidence of low blood pressure. Please document any associated diagnosis.      


Rules

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*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001503*     Future Development - Pulmonary Hypertension        


Rules

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Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
50101 Medication evidence of a vasopressor and clinical evidence of hypotension (+/- clinical evidence of hypotension or documentation of shock) without documentation of the etiology or type of shock LOW BP AND PRESSOR

There is evidence of low blood pressure and a vasopressor. Please document any associated diagnosis.
50102 Documentation of hemorrhagic shock without documentation of hypovolemic shock HEMORRHAGIC SHOCK

Hemorrhagic shock has been documented. Please document that hypovolemic shock is present.
 
50103 Documentation of shock without documentation of the etiology or type of shock SHOCK

Please document the type of shock.
51001427A Documentation of SBP < 90 mmHg and vasopressor or documentation of SBP < 90 mmHg and blood product administration without documentation of the type of shock There is documentation of hypotension and vasopressor or hypotension and administration of blood products. Please document any associated condition and type.
PedShock-001P 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.
Shock-001A Vital sign evidence of hypotension and documentation or clinical, medication, or lab evidence of hypotension (+/- clinical or lab evidence of organ failure) without documentation of the type of shock (age: > 18 years) CIRCULATORY DISORDER

There is evidence of low blood pressure and organ dysfunction. Please document any associated diagnosis.

Evidence

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E11 CDI2
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

Rules

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Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001463P 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.      


Rules

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Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12001   Documentation of syncope without documentation of the etiology of syncope SYNCOPE

Please document the etiology of syncope, if known.
   

Rules

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Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12026 Documentation of clostridium difficile colitis without documentation of present on admission status C DIFF. COLITIS POA

Please document whether C. difficile colitis was present on admission.
     
12029 Documentation of clostridium difficile colitis without documentation of clostridium difficile diarrhea or infection C. DIFF.

There is evidence of C. difficile. Please document any associated diagnosis.
   


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
60205*     Notification: Documentation of secondary malignant neoplasm of retroperitoneum or peritoneum        
64001 Documentation of cancer of the small intestine without documentation of the affected section of small intestine CANCER OF SMALL INTESTINE

Please document the section of small intestine with cancer.
   
66001 Documentation of colon cancer without documentation of the affected section of the colon COLON CANCER

Please document the section of colon with cancer.
   


Rules

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E11 CDI2 CC MCC HCC MS-DRG
12024   Documentation of gastrointestinal bleed (+/- clinical evidence of gastrointestinal bleed) without documentation of the etiology of the gastrointestinal bleed GI BLEED

Please document the etiology of the GI bleed, if known.
   
12025 Documentation of a gastrointestinal ulcer (+/- clinical evidence of a gastrointestinal ulcer) without documentation of present on admission status GI ULCER POA

Please document whether the ulcer was present on admission.
       


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12000   Documentation of abdominal or pelvic pain without documentation of the etiology of abdominal or pelvic pain ABDOMINAL PAIN

Please document the etiology of abdominal and/or pelvic pain, if known.
       
12003 Documentation of dysphagia without documentation of the etiology of dysphagia DYSPHAGIA

Please document the etiology of dysphagia, if known.
     
12010 Documentation of dysphagia without documentation of the site or phase of dysphagia DYSPHAGIA - SITE

Please document the site and/or phase affected by dysphagia, if known.
       
2003001 Documentation of peritonitis and clinical evidence of abscess or anastomotic leak without documentation of abscess or anastomotic leak PERITONITIS

There is evidence of an abscess or anastomotic leak. If appropriate, please document the associated diagnosis.
22000 Documentation of appendicitis (+/- clinical evidence of appendicitis) without documentation of the presence or absence of generalized or localized peritonitis, peritoneal abscess, or ruptured appendix APPENDICITIS

There is documentation of acute appendicitis. Please document whether or not there are any associated complications.
 
30000 Documentation of colonoscopy (+/- evidence of diagnostic colonoscopy) without documentation of the type of colonoscopy (diagnostic, therapeutic, or screening) COLONOSCOPY

Please document the type of colonoscopy (e.g., screening, diagnostic, therapeutic).
       
410001 Documentation of small bowel removal or transplant (+/- clinical evidence of short bowel syndrome or abdominal CT scan) without documentation of short bowel syndrome BOWEL REMOVAL/TRANSPLANT

There is evidence of small bowel removal or transplant. Please document any associated diagnosis.
   
50208 Documentation of gastrointestinal ulcer (+/- clinical evidence of gastrointestinal ulcer) without documentation of the acuity of gastrointestinal ulcer GASTROINTESTINAL ULCER

Please document the acuity of the ulcer.
51000622 Documentation of bowel ischemia or necrosis without documentation of acuity of bowel ischemia or necrosis BOWEL NECROSIS

Please document the acuity associated with bowel ischemia or necrosis.
InflamDigestive-001 Documentation of peritonitis without documentation of the etiology of peritonitis PERITONITIS ETIOLOGY

Please document the etiology of peritonitis, if known.


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
2003003 Documentation of abdominal CT scan, and clinical evidence of ileus or documentation of possible ileus, without documentation of the presence or absence of ileus ABDOMINAL DISORDER

There is evidence of an abdominal CT and multiple abdominal signs and/or symptoms. Please document any associated diagnosis.
 
50209 Documentation of small bowel obstruction (+/- clinical evidence of small bowel obstruction) without mention of the etiology and type of small bowel obstruction SMALL BOWEL OBSTRUCTION

Please document the etiology and type of small bowel obstruction, if known.
 

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001362A Documentation of hepatic encephalopathy or hepatic failure without documentation of the presence or absence of coma (age >18 years) Hepatic encephalopathy or hepatic failure have been documented. Please confirm the presence or absence of coma.  
51001363A Documentation of hepatic failure without documentation of the acuity and etiology of hepatic failure (age >18 years) Hepatic failure has been documented. Please document the acuity and etiology of the hepatic failure.
57003 Documentation of hepatic encephalopathy without documentation of the etiology of hepatic encephalopathy HEPATIC ENCEPHALOPATHY

Please document **etiology** of hepatic encephalopathy, if known.


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
Cirrhosis-001 Explicit mention of the etiology of cirrhosis and presence or absence of ascites CIRRHOSIS - ETIOLOGY

Please specify etiology of cirrhosis and presence or absence of ascites, if known.
   


Rules

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AAdult Only  PPediatric Only
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Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
50210*     Notification: Documentation of portal hypertension in a radiology report (+/- evidence of portal hypertension)        

Evidence

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E11 CDI2
Diagnoses:
Cirrhosis
Gastrointestinal hemorrhage
Hepatic encephalopathy
Portal hypertension

Clinical signs and symptoms:
Abdominal pain
Splenomegaly
Varicosities: abdominal, gastroesophageal, esophageal

Diagnostic procedures and/or procedure findings:
Ascites
Radiological imaging: abdomen

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
33001 Documentation of hepatitis without documentation of acuity of hepatitis HEPATITIS - ACUITY

Please document the acuity of hepatitis.
 
33002 Documentation of hepatitis without documentation of etiology or type HEPATITIS - ETIOLOGY

Please document the etiology of hepatitis.
33003 Documentation of hepatitis and medication evidence of hepatitis-inducing drug without documentation of presence or absence of drug-induced hepatitis HEPATITIS

There is documentation of hepatitis and medications that could be associated with hepatitis. Please clarify whether these are causally related.
   
33004*     Notification: Documentation of alcoholic hepatitis and ascites        
33005*     Notification: Documentation of hepatitis A, B or C with hepatic coma        
33006*     Notification: Documentation of hepatitis B with delta agent        

Evidence

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E11 CDI2
Diagnoses:
Hepatic coma
Hepatitis

Medications and/or therapeutic treatments:
Hepatitis-inducing medication, such as: acetaminophen, antibiotics, antiepileptics, isoniazid, methotrexate


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51000443 Documentation of malignant ascites without documentation of the primary malignancy site MALIGNANT ASCITES

Please document the primary malignancy site associated with the malignant ascites.
       
60101 Documentation of pancreatic cancer without documentation of affected site of the pancreas PANCREATIC CANCER

Please document the site of pancreatic cancer.
   
60204*     Notification: Documentation of secondary malignant neoplasm of liver or intrahepatic bile duct        
63001 Documentation of cancer of the biliary tract without documentation of intrahepatic, extrahepatic, or ampulla of Vater CANCER OF BILIARY TRACT

Please document the site of biliary cancer.
   
63002*     Notification: Documentation of cancer of the gallbladder        

Evidence

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E11 CDI2
Diagnoses:
Hepatic coma
Hepatitis

Medications and/or therapeutic treatments:
Hepatitis-inducing medication, such as: acetaminophen, antibiotics, antiepileptics, isoniazid, methotrexate


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
36001 Documentation of acute pancreatitis without documentation of the etiology of acute pancreatitis ACUTE PANCREATITIS

Please document the etiology associated with acute pancreatitis, if known.
 
36002 Documentation of acute pancreatitis and clinical or lab evidence of ethanol abuse without documentation of alcohol-induced pancreatitis Evidence of alcohol abuse and acute pancreatitis were documented. Please clarify whether these are causally related.      
36003 Documentation of acute pancreatitis and evidence of pancreatitis-inducing drugs without documentation of drug-induced pancreatitis There is documentation of acute pancreatitis and medications that could be associated with pancreatitis. Please clarify whether these are causally related.      
36004 Documentation of pancreatitis without documentation of the acuity of pancreatitis PANCREATITIS - ACUITY

Please document the acuity of pancreatitis (e.g., acute, subacute, acute on chronic, chronic).
 
50207 Documentation of pancreatitis (+/- clinical evidence of pancreatitis) without documentation of the acuity of pancreatitis PANCREATITIS

Please document the acuity of pancreatitis (e.g., acute, subacute, acute on chronic, chronic).
 

Evidence

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E11 CDI2
Diagnoses:
Alcohol abuse
Anorexia
Biliary colic
Gallbladder calculus
Pancreatitis

Clinical signs and symptoms:
Nausea
Pain: abdomen, epigastrium
Vomiting

Labs:
Blood ethanol: > 0 mg/dL

Medications and/or therapeutic treatments:
Pancreatitis-inducing medication, such as: ACE inhibitors, aminosalicylates, azathioprine, diuretics, estrogen, pentamidine, steroids, sulfonamides, tetracycline, thiopurines, valproic acid, vinca alkaloids

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
14004 Documentation of spondylosis without documentation of the region/site of spondylosis SPONDYLOSIS SITE

Please document the spinal level of spondylosis.
     
14005 Documentation of spondylosis without documentation of the presence or absence of myelopathy or radiculopathy SPONDYLOSIS

Please document any other diagnosis(es) associated with spondylosis.
     
14015A Documentation of osteoarthritis of knee (+/- documentation of radiologic studies of the knee) without documentation of the laterality and type of knee osteoarthritis (age: > 18 years) OSTEOARTHRITIS OF KNEE

Please document the laterality and type of knee osteoarthritis.
       
14017 Documentation of arthritis of knee (+/- documentation of radiologic studies of the knee) without documentation of the laterality and type of arthritis ARTHRITIS OF KNEE

Please document the laterality and type of knee arthritis.
 

Evidence

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E11 CDI2
Diagnoses:
Arthritis: knee
Osteoarthritis: knee
Spondylosis

Diagnostic procedures and/or procedure findings:
Computed tomography (CT): knee
Magnetic resonance imaging (MRI): knee
X-ray: knee

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
60202*   Notification: Documentation of secondary malignant neoplasm of bone SECONDARY BONE NEOPLASM

Secondary malignant neoplasm of bone was documented.
       
60203*     Notification: Documentation of secondary malignant neoplasm of the bone marrow        


Rules

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Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12011 Documentation of abnormal gait without documentation of the type of abnormal gait ABNORMAL GAIT

Please document the type of gait abnormality.
     
14012 Documentation of a meniscus tear of the knee (+/- documentation of radiologic studies of the knee) without documentation of the laterality, type, and medial or lateral meniscus of the knee MENISCUS TEAR

There is documentation of meniscal tear. Please document the type, knee laterality (right or left) and meniscus laterality (medial or lateral).
     
14014 Documentation of a rotator cuff injury (+/- documentation of radiologic studies of the shoulder) without documentation of the laterality, type, and tendon(s) involved in the rotator cuff injury ROTATOR CUFF INJURY

There is documentation of a rotator cuff injury. Please document the type, shoulder laterality, and tendon(s) involved, if known.
   
14016*     Notification: Documentation of date of injury        
50201 Documentation of osteomyelitis (+/- clinical evidence of osteomyelitis) without documentation of acuity of osteomyelitis OSTEOMYELITIS

Please document the acuity of osteomyelitis.
 

Evidence

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E11 CDI2
Diagnoses:
Fall
Injuries: non-traumatic/traumatic
Musculoskeletal injuries: rupture, sprain, strain, tear
Osteomyelitis

Clinical signs and symptoms:
Fatigue
Fever
Gait abnormality
Malaise
Pain: bone, joint, tendon
Rash

Labs:
Creatinine kinase: >= 1000 u/L

Diagnostic procedures and/or procedure findings:
Computed tomography (CT) : knee, shoulder
Magnetic resonance imaging (MRI) : knee, shoulder
Radiographic imaging (X-Ray) : knee, shoulder

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
50204 Documentation of gout without documentation of the site and acuity of gout GOUT

Please document the acuity and site of gout.
     


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
14000 Documentation of a fracture (+/- clinical evidence of a stress fracture) without documentation of stress fracture FRACTURE

Please document the type of fracture (e.g., traumatic, stress, pathological).
   
14001 Documentation of a nontraumatic fracture and clinical, medication, or radiologic evidence of osteoporosis without documentation of pathologic fracture FRACTURE TYPE - B

There is evidence of fracture, osteoporosis, and no evidence of major trauma. Please document the type of fracture.
 
14002 Documentation of malignancy and a nontraumatic fracture without documentation of pathologic fracture FRACTURE TYPE - C

There is evidence of fracture, malignancy, and no evidence of major trauma. Please document the type of fracture.
 
14003 Documentation of a bone disease and a nontraumatic fracture without documentation of pathologic fracture FRACTURE - B

There is evidence of fracture and bone disease, and no evidence of major trauma. Please document the type of fracture.
 
14009 Documentation of fracture without documentation of the alignment, stability, and type of fracture FRACTURE TYPE

Please document the type (e.g., traumatic, stress, pathological), alignment (i.e., angulated, displaced, non-displaced, dislocated, rotated), and stability of fracture, if known.
   


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
14019A Clinical and lab evidence of rhabdomyolysis without documentation of rhabdomyolysis (age: > 18 years) HIGH CK AND TRAUMA

There is evidence of creatine kinase >1000 U/L and trauma. Please document any associated diagnosis.
     

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
62001 Documentation of breast cancer without documentation of site and laterality of affected breast BREAST CANCER

Please document the site and laterality of breast cancer.
     

Evidence

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Product Evidence
E11 CDI2
Diagnoses:

Infiltrating Ductal Carcinoma Stage 1-4

Lobular Carcinoma

Metastatic Breast Cancer


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
20007 Documentation of an ulcer, and documentation or lab or medication evidence of diabetes, without documentation of the relationship between the ulcer and diabetes ULCER-DIABETES RELATIONSHIP

There is documentation of an ulcer and documentation or evidence of an endocrine condition. Please clarify whether these are causally related.
       
20009*   Notification: Documentation of a pressure ulcer, injury, wound, or sore SKIN CONDITION - B

There is documentation of a pressure ulcer/injury/wound/sore.
       
20014 Documentation of a pressure ulcer without documentation of present on admission status PRESSURE ULCER POA

If condition was present on admission (clinical signs evident within 24 hours of presentation) then please document **POA status**.
     
20016 Documentation of a skin ulcer without documentation of the type of skin ulcer SKIN ULCER TYPE

Please document the type of skin ulcer.
 
20019 Documentation of a non-pressure ulcer without documentation of the type, number, present on admission status, and site of the non-pressure ulcer NON-PRESSURE ULCER

Please make sure you are defining the **type**, **site**, **POA status**, **number** and **laterality** of the non-pressure ulcer.
   
20024   Documentation of a pressure ulcer without documentation of the laterality, number, site, stage, and present on admission status of the pressure ulcer PRESSURE ULCER

There is explicit mention of a pressure ulcer. Please verify that all defining attributes have been identified (site, stage, laterality, number, POA).
     
SkinLesions-001 Documentation of a ulcer and diabetes without documentation of the relationship between the ulcer and diabetes DIABETIC ULCER

There is explicit mention of ulcer and diabetes, if true, please confirm if ulcer is related to diabetes.
       
SkinLesions-002 Documentation of a pressure ulcer without documentation of present on admission status and the site of the pressure ulcer PRESSURE ULCER SITE AND POA

Please document the site of the pressure ulcer and whether it was present on admission.
     

Evidence

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E11 CDI2
Diagnoses:
Abscess

Avulsion

Bites

Blisters

Burn

Cancer

Cellulitis

Debridement

Dermatophilosis

Ephelis

Fibroepithelial polyp

Keloid scar

Laceration

Puncture of the skin

Seborrheic keratosis

Trauma

Ulcer

Wound

Clinical signs and symptoms:
Elevated temperature: > 101.0 Fahrenheit, 38.3 Celsius

Impaired skin integrity

Wound dehiscence

Wound discharge

Wound erythema

Wound infection

Wound odor

Wound pain

Medications and/or therapeutic treatments:
Diabetic medications

Diagnostic procedures and/or procedure findings:
Wound repair

Incision and drainage


Rules

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E11 CDI2 CC MCC HCC MS-DRG
19000 Documentation of sharp debridement or debridement and instrument evidence of excisional debridement (+/- evidence of the depth or level, size, or type of wound) without documentation of excisional debridement DEBRIDEMENT

Please document the type of debridement performed.
       
19001   Documentation of excisional debridement (+/- evidence of wound characteristics or debridement level) without documentation of sharp debridement or instrument evidence of excisional debridement        
19002*   Notification: Documentation of debridement DEBRIDEMENT - ST. CLAIRE

Mention of debridement in current document. Please refer to the **wound debridement form** in the **assessment section** to document all necessary items for this debridement.
       
19003   Documentation of debridement (+/- instrument evidence of excisional debridement) without documentation of whether the debridement is excisional or non-excisional DEBRIDEMENT - B

Please document the type of debridement performed.
       
19004 Documentation of debridement (+/- instrument evidence of excisional debridement) without documentation of the depth or level of debridement DEBRIDEMENT - DEPTH/LEVEL

Please document the depth of debridement.
       
Debridement-001 Documentation of debridement (+/- instrument evidence of excisional debridement) without documentation of depth or level of debridement and whether the debridement is excisional or nonexcisional DEBRIDEMENT - TYPE/DEPTH

Please document the type of debridement and the deepest layer of tissue removed.
       


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E11 CDI2 CC MCC HCC MS-DRG
12005 Documentation of an erythematous condition without documentation of the type of erythematous condition ERYTHEMATOUS CONDITION

Please document the type of the erythematous condition.
   
20010 Documentation of incision and drainage without documentation of the depth or level of the incision and drainage INCISION AND DRAINAGE

Incision and drainage is documented. Please document the depth of tissue involved.
       
20020*     Notification: Documentation of a surgical incision        
2003002 Documentation of a wound and clinical evidence of a wound infection without documentation of the presence or absence of a wound infection WOUND

There is evidence of elevated temperature and/or signs and symptoms related to the wound in addition to documentation of a wound. Please document any associated condition.
   
OtherSkinAndSubQ-001*     Notification: Documentation of impaired skin integrity        

Evidence

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E11 CDI2
Diagnoses:
Wound

Clinical signs and symptoms:

Elevated temperature: > 101.0 Fahrenheit, 38.3 Celsius
Wound dehiscence
Wound discharge
Wound erythema
Wound infection
Wound odor
Wound pain


Medications and/or therapeutic treatments:
Wound VAC

Diagnostic procedures and/or procedure findings:
Wound culture

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
60206*     Notification: Documentation of secondary malignant neoplasm of skin        

Evidence

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E11 CDI2
Diagnoses:

Metastatic Crohn’s Disease of the skin

Secondary Neoplasm of the skin


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
20005*   There is evidence of skin lesion, ulcer, wound, or burn, please verify that all defining attributes have been identified (site, laterality, state, size, number, cause, and if POA). Please make sure you are defining all of the **attributes** of each skin lesion, ulcer, wound, or burn (site, laterality, state, size, number, cause, and if POA).        
20006 Documentation of a skin lesion, ulcer, or wound without documentation of present on admission status SKIN LESION POA

Please document if skin lesion was present on admission.
     
20017 Documentation of a skin lesion, ulcer, or wound without documentation of present on admission status and the type of skin lesion, ulcer, or wound WOUND TYPE

Please document the type of wound and whether it was present on admission.
       
20021   Documentation of a burn, skin lesion, ulcer, or wound without documentation of the laterality, number, site or present on admission status SKIN LESION/WOUND

Please document the site, laterality, number, and POA status of skin lesion or wound.
       
20022   Documentation of a skin lesion, ulcer, or wound without documentation of the etiology of the skin lesion, ulcer, or wound SKIN CONDITION - ETIOLOGY

There is documentation of a skin lesion, pressure ulcer, primary ulcer or wound. Please document the etiology, if known.
       
20023   Documentation of a skin lesion, ulcer, or wound without documentation of the episodicity or etiology of the lesion, ulcer, or wound SKIN CONDITION - STATE

There is explicit mention of a skin lesion, pressure ulcer, or wound, please verify the state.
       
20025*   Documentation of a burn, skin lesion, ulcer, or wound without documentation of the burn, skin lesion, ulcer, or wound measurement SKIN CONDITION - SIZE

Please document the measurements of the skin lesion, pressure ulcer, or wound.
       

Rules

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E11 CDI2 CC MCC HCC MS-DRG
26000 Lab evidence of respiratory alkalosis (+/- clinical evidence or documentation of the etiology of respiratory alkalosis) without documentation of respiratory alkalosis LOW PCO2 AND HIGH PH

There is evidence of pCO2 <35mmHg and pH >7.45. Please document any associated diagnosis.
   
26001 Lab evidence of respiratory acidosis (+/- clinical evidence or documentation of the etiology of respiratory acidosis) without documentation of respiratory acidosis HIGH PCO2 AND LOW PH

There is evidence of pCO2 > 45mmHg and pH < 7.35. Please document any associated diagnosis.
   
26002 Lab evidence of metabolic alkalosis (+/- clinical evidence or documentation of the etiology of metabolic alkalosis) without documentation of metabolic alkalosis HIGH PH AND HCO3

There is evidence of high pH and HCO3. Please document any associated diagnosis.
   
26003 Lab evidence of metabolic acidosis (+/- clinical evidence or documentation of the etiology of metabolic acidosis) without documentation of metabolic acidosis LOW PH AND HCO3

There is evidence of low pH and HCO3. Please document any associated diagnosis.
 

Evidence

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E11 CDI2
Diagnoses:
Lactic Acidosis

Metabolic Acidosis

Metabolic Alkalosis

Respiratory Acidosis

Respiratory Alkalosis

Clinical signs and symptoms:
Anxiety

Asthenia

Cardiac arrhythmias

Chest pain

Confusion

Decreased skin turgor

Dizziness

Drowsiness

Drug overdose

Dyspnea

Fatigue

Hyperventilation

Hypotension

Hypoventilation

Ketotic breath

Lethargy

Muscle weakness

Palpitations

Paresthesia

Polyuria

Restlessness

Seizure

Syncope

Tetany

Vertigo

Labs:
Alkalosis:

HCO3: > 27 mEq/L

pCO2: < 35 mmHg

pH: > 7.45

Acidosis:

HCO3: < 22mEq/L

pCO2: > 45 mmHg

pH: < 7.35

Lactate: > 4mmol/L


Rules

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E11 CDI2 CC MCC HCC MS-DRG
40203P 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.      
40204P 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*P     Pediatric notification: Documentation of BMI between the 5th and 85th percentile for age        
40208*P     Pediatric notification: Documentation of BMI between the 85th and 95th percentile for age        
40209*P     Pediatric notification: Documentation of BMI at or above the 95th percentile for age        


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E11 CDI2 CC MCC HCC MS-DRG
40501 Documentation of cystic fibrosis without documentation of manifestation of cystic fibrosis CYSTIC FIBROSIS

Please document any manifestations to cystic fibrosis


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
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E11 CDI2 CC MCC HCC MS-DRG
21000*     Notification: Documentation of diabetes and lab or clinical evidence of a primary complication of diabetes (+/- documentation of a secondary complication of diabetes)        
21002 Documentation of diabetes without documentation of the type of diabetes DIABETES MELLITUS

Please document the type of diabetes mellitus.
21003*     Notification: Documentation of insulin therapy        
21004*     Notification: Documentation of an insulin pump (+/- evidence of insulin pump malfunction)    
21005*     Notification: Documentation of both diabetes type 1 and type 2        
21006 Documentation of diabetes and a complication of diabetes without documentation of the relationship between diabetes and the complication DIABETIC COMPLICATION

Diabetes is documented. Please document any causally related complication of the diabetes.
21007*     Notification: Documentation of diabetes and a complication of diabetes        
21009 Documentation of poorly controlled or uncontrolled diabetes without documentation of hyperglycemia or hypoglycemia UNCONTROLLED DIABETES

Please consider documenting **hyperglycemia** or **hypoglycemia** in coordination with the mention of uncontrolled diabetes.
   
43002 Documentation or lab evidence of diabetic ketoacidosis and documentation or clinical evidence of coma without documentation of diabetic ketoacidosis with coma SEVERE DIABETES

There is documentation or evidence of an endocrine and neurological disorder. Please document the relationship, if applicable.
   
43003 Lab evidence of diabetic ketoacidosis without documentation of diabetic ketoacidosis DIABETIC COMPLICATION - B

There is evidence of a severe diabetic complication, please document if known.
   
43007 Documentation of diabetes without documentation of whether diabetes is controlled or uncontrolled DIABETES COURSE

Please document the course (controlled/uncontrolled) of diabetes.
   
51001444A 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) (age: > 18 years) GESTATIONAL DIABETES - TYPE

Please document the type of gestational diabetes
       
Diabetes-001 Lab evidence of diabetes without documentation of the type of diabetes HIGH GLUCOSE AND A1C

There is evidence of glucose >180 mg/dL and HbA1c >6.5%. Please document any associated diagnosis.
Diabetes-002 Documentation and lab evidence of hyperglycemia without documentation of the etiology of hyperglycemia HYPERGLYCEMIA AND DIABETES RELATIONSHIP/UNKNOWN ETIOLOGY

Hyperglycemia or evidence of hyperglycemia were documented, but the etiology was not documented.

Evidence

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E11 CDI2
Diagnoses:
Chronic kidney disease

Coma

Diabetes mellitus type 1

Diabetes mellitus type 2

Diabetic ketoacidosis

Gangrene

Gestational diabetes

Hyperglycemia

Neuropathy

Peripheral vascular disease

Retinopathy

Skin ulcer

Labs:
Diabetic ketoacidosis

Glucose: >200 mg/dL

pH: <7.3

HbA1c: >= 6.5%

Hypoglycemia:

Glucose: <70 mg/dL

Medications and/or therapeutic treatments:
Insulin

Neuropathic medications



Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001445P 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
       


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
24001 Lab evidence of hyponatremia (+/- evidence of treatment for hyponatremia) without documentation of hyponatremia LOW SODIUM

There is evidence of low sodium. Please document any associated diagnosis.
     
24002 Lab evidence of hypernatremia (+/- evidence of treatment for hypernatremia) without documentation of hypernatremia HIGH SODIUM

There is evidence of high sodium. Please document any associated diagnosis.
     
24003 Lab evidence of hypokalemia (+/- evidence of treatment for hypokalemia) without documentation of hypokalemia LOW POTASSIUM

There is evidence of low potassium. Please document any associated diagnosis.
       
24004 Lab evidence of hyperkalemia (+/- evidence of treatment for hyperkalemia) without documentation of hyperkalemia HIGH POTASSIUM

There is evidence of high potassium. Please document any associated diagnosis.
       
24005 Lab evidence of hypocalcemia (+/- evidence of treatment for hypocalcemia) without documentation of hypocalcemia LOW CALCIUM

There is evidence of low calcium. Please document any associated diagnosis.
     
24006 Lab evidence of hypercalcemia (+/- evidence of treatment for hypercalcemia) without documentation of hypercalcemia HIGH CALCIUM

There is evidence of high calcium. Please document any associated diagnosis.
       
24007 Lab evidence of hypomagnesemia (+/- evidence of treatment for hypomagnesemia) without documentation of hypomagnesemia LOW MAGNESIUM

There is evidence of low magnesium. Please document any associated diagnosis.
     
24008 Lab evidence of hypermagnesemia (+/- evidence of treatment for hypermagnesemia) without documentation of hypermagnesemia HIGH MAGNESIUM

There is evidence of high magnesium. Please document any associated diagnosis.
       
51001002 Lab evidence of hypophosphatemia (+/- evidence of treatment for hypophosphatemia) without documentation of hypophosphatemia There is evidence of low phosphate. Please document any associated diagnosis.        
51001003 Lab evidence of hyperphosphatemia (+/- evidence of treatment for hyperphosphatemia) without documentation of hyperphosphatemia There is evidence of high phosphate. Please document any associated diagnosis.        

Evidence

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E11 CDI2
Labs:

High calcium

Adults (ages > 18): >= 13 mg/dL

Children (ages <= 18): >= 12 mg/dL

High magnesium

Adults (ages > 18): >= 4.7 mg/dL

Children (ages <= 18): >= 3 mg/dL

High phosphate

Adults (ages > 18): > 4.5 mg/dL

Children (ages <= 18): gender & age-based values

High potassium

Adults (ages > 18): >= 6.2 mmol/L

Children (ages <= 18): >= 5.5 mmol/L

High sodium

Adults (ages > 18): > 145 mEq/L

Children (ages <= 18): >= 145 mEq/L

Low calcium

Adults (ages > 18): <= 6 mg/dL

Children (ages <= 18): <= 8 mg/dL

Low magnesium

Adults (ages > 18): <= 1 mg/dL

Children (ages <= 18): < 1.2 mg/dL

Low phosphate

Adults (ages > 18): < 2 mg/dL

Children (ages <= 18): gender & age-based values

Low potassium

Adults (ages > 18): <= 2.8 mmol/L

Children (ages <= 18): <= 2.5 mmol/L

Low sodium

Adults (ages > 18): <= 130 mEq/L

Children (ages <= 18): <= 130 mEq/L


Medications and/or therapeutic treatments:

Bisphosphonates

Corticosteroids

Diuretics

Electrolytes: calcium, magnesium, phosphate, potassium, sodium

Insulins

Ion exchange resins

IV fluid administration

Phosphate binders

RANK ligand inhibitors

Vasopressin receptor antagonists


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
26004A Lab evidence of lactic acidosis without documentation of lactic acidosis (age: > 18 years) ELEVATED LACTATE

There is evidence of lactate >4 mmol/L. Please document the associated diagnosis of this indicator.
   


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
13000A Lab or medication evidence of malnutrition, and clinical evidence of malnutrition, without documentation of the severity and/or type of malnutrition (age: > 18 years) NUTRITIONAL INDICATORS - G

Evidence of a nutritional condition is present, if true, please specify a corresponding condition with **severity** (mild, moderate or severe) and **type** (calorie or protein-calorie).
13002*A     Notification: Lab evidence of malnutrition (+/- clinical or medication evidence of malnutrition or evidence of pressure ulcer) (age: > 18 years)        
13003*A     Notification: Documentation of BMI less than or equal to 19 (+/- clinical, lab, or medication evidence of malnutrition) (age: > 18 years)        
13005 Documentation of malnutrition (+/- clinical, lab, or medication evidence of malnutrition or BMI <=19) without documentation of the severity and type of malnutrition MALNUTRITION

Please specify the severity and type of malnutrition.
13006A   Documentation of TPN or tube feeding (+/- clinical, lab, or medication evidence of malnutrition) without documentation of severity of malnutrition (age: > 18 years) TPN/TUBE FEEDING

There is documentation of TPN/tube feeding. Please document any associated diagnosis.
13007 BMI <=19 or medication evidence of malnutrition, and clinical evidence of malnutrition, without documentation of the severity and/or type of malnutrition NUTRITIONAL INDICATORS - C

Evidence or explicit mention of malnutrition is present, if true, please specify the "severity" (mild, moderate or severe).
 
13008*A     Notification: Documentation of BMI less than or equal to 19.5 (+/- clinical, lab, or medication evidence of malnutrition) (age: > 18 years)        
13009A Documentation of malnutrition (+/- clinical, lab, or medication evidence of malnutrition) without documentation of the severity of malnutrition (age: > 18 years) MALNUTRITION - SEVERITY

Please specify the severity of malnutrition.
 
13012*A     Notification: Documentation of BMI less than or equal to 19 or clinical evidence of ASPEN criteria (+/- evidence of height or weight) (age: > 18 years)        
13013A   Documentation of BMI <=19 without clinical evidence of malnutrition (age: > 18 years) LOW BMI

There is evidence of Malnutrition.
     
Malnutrition-004A Documentation of BMI less than or equal to 19 (+/- clinical or medication evidence of malnutrition or evidence of pressure ulcer) without documentation of the severity of malnutrition (age: > 18 years) NUTRITIONAL INDICATORS - D

There is evidence of BMI <= 19 and clinical indicators of a potential nutritional deficiency. Please document any associated diagnosis and severity
 
Malnutrition-005 BMI <=19, medication, and/or clinical evidence of malnutrition (+/- documentation of malnutrition) without documentation of severity of malnutrition NUTRITIONAL INDICATORS - E

Evidence or explicit mention of malnutrition is present, if true, please specify the "severity" (mild, moderate or severe).
 
Malnutrition-006A Documentation of malnutrition without documentation of BMI <=19 and medication or clinical evidence of malnutrition (age: > 18 years) MALNUTRITION - B

Please include the clinical indicators supporting the diagnosis of malnutrition.
Malnutrition-007A Documentation of malnutrition without documentation of protein-calorie malnutrition and severity (age: > 18 years) MALNUTRITION TYPE/ACUITY

Please document the type and severity of malnutrition.
 
Malnutrition-008A BMI <= 19 or lab evidence of cachexia or failure to thrive, and clinical evidence of cachexia or failure to thrive, without documentation of cachexia or failure to thrive (age: > 18 years) NUTRITIONAL INDICATORS - H

There is evidence of failure to thrive or cachexia. If appropriate, please document or specify other condition.
PedMalnutrition-003 Documentation of TPN or tube feeding (+/- clinical or medication evidence of malnutrition) without documentation of severity of malnutrition (age: < 21 years) TPN AND/OR TUBE FEEDING

There is evidence of TPN and/or tube feeding. Please document any associated diagnosis.

Evidence

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Product Evidence
E11 CDI2
Diagnoses:
Anorexia

Failure to thrive

Hypoalbuminemia

Inanition

Kwashiorkor

Normocytic anemia

Nutritional marasmus

Sarcopenia

Ulcer

Clinical signs and symptoms:
Anasarca

Body height

Body mass index (BMI):

 Adult (ages < 19): < 19

 Children (ages <= 19): < 3 %% (percentile)/age

Body weight

Cachexia

Decreased appetite

Edema

Emaciated

Food deprivation

Hair: brittle, fine, loss

Impaired wound healing

Muscle atrophy

Skin: dry, thin, decreased turgor

Starvation

Sunken temples

Underweight

Labs:
Albumin:

 Adults (ages >18): <= 2.9 g/dL

 Children (ages <=18): <= 3.4 g/dL

Pre-albumin: <= 15 g/dL

Medications and/or therapeutic treatments:
Anabolic steroids

Antidepressants

Antiemetics

Button gastrostomy

Cannabinoids

Dietary supplements

Esophagostomy

Nutritional therapy

Diagnostic procedures and/or procedure findings:
Total parenteral nutrition (TPN)

Enteral feeding


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
40206*P     Pediatric notification: Documentation of BMI below the 5th percentile for age        
40211P 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.


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
23001*A     Notification: Documentation of BMI greater than or equal to 40 and evidence of amputation (age: > 18 years)        
23003A Documentation of BMI greater than or equal to 30 without documentation of obesity (age: > 18 years) HIGH BMI

There is evidence of BMI greater than or equal to 30 . Please document any associated diagnosis
 
23004A Documentation of BMI greater than or equal to 25 and less than 30 without documentation of overweight (age: > 18 years) HIGH BMI - C

There is evidence of BMI greater than or equal to 25 and less than 30. Please document any associated diagnosis
     
23005A Documentation of BMI greater than or equal to 30 and less than 40 without documentation of obesity (age: > 18 years) HIGH BMI - B

There is evidence of BMI greater than or equal to 30 and less than 40. Please document any associated diagnosis
     
23006A Documentation of BMI greater than or equal to 40 (+/- documentation of obesity) without documentation of severe, class 3, or morbid obesity (age: > 18 years) HIGH BMI - D

There is evidence of BMI greater than or equal to 40. Please document any associated diagnosis
 
23007*A     Notification: Documentation of obesity or morbid obesity and medication evidence of obesity-inducing drug (age: > 18 years)        
23008   Documentation of obesity or morbid obesity without documentation of the etiology of obesity or morbid obesity  
23009 Documentation of obesity or morbid obesity and arterial pCO2 greater than 45 or clinical evidence of hypoventilation without documentation of alveolar hypoventilation or Pickwickian syndrome OBESITY AND HIGH CO2

There is documentation of obesity and evidence of arterial carbon dioxide > 45 mmHg. Please document any associated diagnosis.
 
Obesity-001*A   Notification: Documentation of BMI greater than or equal to 40 without documentation of overweight, obesity, severe obesity, or morbid obesity (age: > 18 years)        
Obesity-002A Documentation of BMI greater than 35 without documentation of class 2, 3, severe, or morbid obesity (age: > 18 years) HIGH BMI - ADULT

Please document a corresponding condition related to high BMI, if applicable.
 

Evidence

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E11 CDI2
Diagnoses:
Limb amputation

Obesity

Obstructive sleep apnea

Clinical signs and symptoms:
Hypoventilation

Morbid obesity:

Body mass index (BMI):

Adult (ages > 18):

Overweight: BMI 25-30 kg/m2

Obesity: BMI 30-40 kg/m2

Medications associated with obesity

Morbid obesity: BMI > 40 kg/m2

Children (ages <=18):

Class I obesity: BMI 30-<35 kg/m2 or 95-<99 percentile

Class II/III obesity: BMI >= 35 kg/m2 or >= 99 percentile

Labs:
pCO2: > 45 mmHg


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12018 Documentation of thyrotoxicosis without documentation of the etiology of thyrotoxicosis THYROTOXICOSIS

Please document the etiology of thyrotoxicosis.
     
51001182A Documentation of a thyroid medication without documentation of a thyroid condition There is documentation of thyroid medication. Please document any associated diagnosis.

Evidence

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Product Evidence
E11 CDI2
Diagnoses:
Grave's disease
Idiopathic thyrotoxicosis

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51000302A Creatinine greater than 2 mg/dL, and documentation of renal insufficiency or clinical, other lab, or medication evidence of renal disease or failure, without documentation of renal failure, injury, or disease (age: > 18 years) RENAL DISORDER /ABNORMAL CREATININE

There is evidence of elevated creatinine and other clinical and/or lab indicators of renal disease. Please document any associated diagnosis.
51000722 Documentation of tumor lysis syndrome and allopurinol or rasburicase without documentation of whether tumor lysis syndrome treatment is active or prophylactic Please specify treatment status of tumor lysis syndrome.      
6000 Documentation of acute renal insufficiency or pre-renal azotemia (+/- clinical or lab evidence of acute renal failure) without documentation of acute renal failure RENAL INSUFFICIENCY

There is documentation of acute renal insufficiency or pre-renal azotemia. Please document a more specific diagnosis, if known.
6001A Lab evidence of acute renal failure (+/- clinical evidence of acute renal failure) without documentation of acute renal failure (age: > 18 years) RENAL DISORDER - B

There is evidence of an increase in creatinine levels. Please document any associated diagnosis.
6003*A   Notification: Documentation of creatinine >= 1.5 and prerenal azotemia or dehydration (+/- clinical evidence of acute renal failure or dehydration) (age: > 18 years)        
6006 Documentation of acute renal failure (+/- clinical or lab evidence of acute renal failure) without documentation of the site of kidney injury ACUTE KIDNEY DISEASE

There is documentation of acute kidney injury or renal failure. Please document a more specific diagnosis, if known.
   
6008*A   Notification: Documentation of acute renal failure (+/- clinical or lab evidence of acute renal failure) (age: > 18 years)        
6009 Documentation of acute renal failure (+/- clinical or lab evidence of acute renal failure) without documentation of the etiology of acute renal failure ACUTE KIDNEY DISEASE - CAUSE

Please document the etiology of acute renal failure, if known.
   
6010A Documentation of acute renal failure (+/- clinical evidence of acute renal failure) without lab evidence of acute renal failure or documentation of the etiology of acute renal failure (age: > 18 years) ACUTE RENAL FAILURE - CLINICAL INDICATORS

Please include the clinical indicators supporting the diagnosis of acute renal failure.
6011*   Notification: Documentation of the acuity of kidney failure or disease (+/- clinical or lab evidence of kidney disease)
9005* Notification: Use of the abbreviation ""AKI"" without documentation of the associated medical term AKI ABBREVIATION

The abbreviation of AKI has been documented. Please document a more specific diagnosis.
       
9006 Documentation of acute kidney injury and documentation of intra-renal or intrinsic renal failure (+/- clinical or lab evidence of acute renal failure) without documentation of acute tubular necrosis RENAL DISORDER - LOCATION

Acute kidney injury, and intra-renal disease or intrinsic renal disease were documented. Please document the location of the renal disorder or any other corresponding conditions that may be present.
 

Evidence

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Product Evidence
E11 CDI2
Diagnoses:
Albuminuria
Anaphylaxis
Anemia
Anorexia
Cardiac arrest
Chronic kidney disease
Cirrhosis
Coma
Congestive heart failure
Diabetes mellitus
Electrolyte imbalance: hypercalcemia, hyperkalemia, hypernatremia, hyperphosphatemia
End stage renal disease
Full thickness burn
Graves’ disease
Hepatorenal syndrome
Hypertension
Hypotension
Hypovolemia
Kidney injury
Liver failure
Lupus
Medication overdose: diuretics, non-steroidal anti-inflammatory drugs (NSAID)
Medication poisoning: lithium
Myocardial infarction
Necrosis: kidney cortex, papillary, renal medullary, tubular
Nephritis
Pancreatitis
Renal failure
Renal impairment
Rhabdomyolysis
Sepsis
Shock
Systemic inflammatory response syndrome (SIRS)
Thrombosis
Tumor lysis syndrome
Uremic syndrome
Urinary obstruction

Clinical signs and symptoms:
Chest pain
Chest tightness
Confusion
Decreased urine output
Dehydration
Edema
Fatigue
Irregular heartbeat
Nausea
Seizure
Short of breath
Vomiting
Weakness

Labs:
Fractional excretion of sodium (FENa): > 2%
Glomerular filtration rate (GFR):
Evidence for chronic kidney disease (CKD): GFR < 60 mL/min/1.73m2
Evidence for CKD stage 3a and 3b:
CKD Stage 3a: GFR >= 45 to < 60 mL/min/1.73m2
CKD Stage 3b: GFR >=30 to < 45 mL/min/1.73m2
Serum creatinine: >= 1.5 mg/dL or
Increased serum creatinine: 0.3 mg/dL increase from baseline of >= 1.3 mg/dL within 48 hours
Increased serum creatinine: 50% increase from baseline >= 1.3 mg/dL within 7 days
Urine sodium: > 40 mEq/L

Medications and/or therapeutic treatments:
Chemotherapy
Dialysis
Diuretics
Nephrotoxins
Nonpegylated recombinant uricase
Xanthine oxidase inhibitors


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
6004A Clinical and lab evidence of acute tubular necrosis without documentation of acute tubular necrosis (age: > 18 years) RENAL DISORDER

There is evidence of high fractional excretion of sodium and/or urine sodium. Please document any associated diagnosis.
   
6007*A   Notification: Documentation of acute tubular necrosis (+/- lab evidence) (age: > 18 years)        


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
9000 Documentation and lab evidence of chronic kidney disease (+/- clinical evidence of chronic kidney disease) without documentation of the stage of chronic kidney disease KIDNEY DISEASE

Please document the stage of chronic kidney disease.
9001*A     Use of ICD-10 code for ESRD (N18.6) with mention/evidence of ESRD        
KidneyDisease-001 Documentation of chronic kidney disease stage 3 with specificity of 3a/3b CKD STAGE 3 SPECIFICITY

Please specify whether the CKD is stage 3a or 3b.
     
KidneyDisease-002 Documentation of creatinine > 1.5 without documentation of acute or chronic kidney disease CREATININE > 1.5

There is evidence of creatinine >1.5. Please document any associated diagnosis.
   


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12004 Documentation of hematuria without documentation of the type of hematuria HEMATURIA

Please document the type of hematuria.
 
12013 Documentation of urethral stricture without documentation of the type of urethral stricture URETHRAL STRICTURE

Please document the etiology of urethral stricture (e.g., post-traumatic, post-infective).
       
12014 Documentation of urolithiasis or urinary calculus (+/- clinical evidence of urinary calculus) without documentation of the site of urolithiasis or urinary calculus URINARY CALCULUS

Please document the site of the urinary calculus, if known.
     
12015 Documentation of urinary calculus without documentation of the presence or absence of hydronephrosis or obstruction URINARY CALCULUS COMPLICATIONS

There is documentation of a urinary calculus. Please document any associated complication.
   

Evidence

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Product Evidence
E11 CDI2
Diagnoses:
Nephrotic syndrome
Urethral stricture
Urinary calculus

Clinical signs and symptoms:
Chills
Difficulty passing urine
Fever
Nausea
Pain: flank, during urination
Urinary urgency
Urine: bloody, cloudy, malodorous
Vomiting


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
16011*     Notification: Documentation of a urinary tract infection and the presence of a urinary device        
16014 Documentation of urinary tract infection without documentation of present on admission status URINARY TRACT INFECTION

Please document whether UTI was present on admission.
     
16016*     Notification: Documentation that UTI was present on admission        
16029 Documentation of a urinary tract infection and the presence of a urinary device without documentation of urinary tract infection due to urinary device UTI - URINARY DEVICE - B

There is evidence of a urinary device and documentation of a urinary tract infection. Please document whether these are causally related.
 
16031 Documentation of a catheter associated urinary tract infection without documentation of present on admission status CAUTI POA

Please document whether catheter associated urinary tract infection was present on admission.
   
50203 Documentation of pyelonephritis (+/- clinical evidence of pyelonephritis) without documentation of acuity of pyelonephritis PYELONEPHRITIS

Please document the acuity of pyelonephritis.
   
51001282A Documentation of UTI in the emergency department without documentation of UTI in the inpatient documentation (age >18 years) UTI is documented in the emergency department but has not been documented after admission. Please clarify the presence or absence of this diagnosis.        
51001283A Documentation of catheter associated UTI in the emergency department without documentation of catheter associated UTI in the inpatient documentation (age >18 years) 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.        

Evidence

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E11 CDI2
Diagnoses:
Catheter-associated urinary tract infection (CAUTI)
Cystitis
Pyelonephritis
Urinary tract infection (UTI)

Clinical signs and symptoms:
Chills
Fever
Nausea
Pain: abdomen, back, flank, inguinal
Presence of urinary device: nephrostomy tube, stent, urinary catheter
Urination: increased frequency, painful, urgency
Urine: bloody, cloudy, malodorous, turbid
Vomiting

Medications and/or therapeutic treatments:
Urinary catheterization


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001422P 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.        
51001423P 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.        

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51000386 Documentation of uterine cancer without documentation of the site of cancer within the uterus UTERINE CANCER

Please document the site of uterine cancer (e.g., endometrium, myometrium, fundus uteri, overlapping, unspecified).
     
51000402 Documentation of cervical cancer without documentation of the site of cancer within the cervix CERVICAL CANCER

Please document the site of cervical cancer (e.g., endocervix, exocervix, overlapping, unspecified).
     
51000403 Documentation of fallopian tube cancer without documentation of laterality or specific site FALLOPIAN TUBE CANCER

Please document the laterality of the fallopian tube affected by fallopian tube cancer.
     
69001 Documentation of ovarian cancer without documentation of the laterality of affected ovary OVARIAN CANCER

Please document the laterality of ovarian cancer.
   

Evidence

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Product Evidence
E11 CDI2
Diagnoses:
Cancer: cervical, endometrial, fallopian tubes, ovarian, uterine


Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51000902 Evidence of pre-term labor without documentation of pre-term labor There is evidence of preterm labor. Please document preterm labor, if appropriate.  
51000923* Notification: Documentation of relevant infection during pregnancy There is documentation of a gynecological and/or other relevant infection during this pregnancy        
51000982 Documentation of perineal laceration or repair without documentation of degree of laceration A perineal laceration or wound repair was documented. Please document the degree of laceration.        
51001082 Documentation of postpartum and blood loss > 1000 ml without documentation of postpartum hemorrhage A postpartum female with a blood loss >1000 ml has been documented. Please document the associated disorder.    
51001402A Documentation of a thyroid medication during pregnancy without documentation of a thyroid condition (age: > 18 years) There is documentation of thyroid medication during pregnancy. Please document any associated diagnosis.    
51001462P 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.    
GestDiabetes-001 Documentation of gestational diabetes without documentation of the type of gestational diabetes and the associated trimester GESTATIONAL DIABETES

Please document the type of gestational diabetes and associated trimester.
     
PreEclampsia-001 Documentation of pre-eclampsia without documentation of the severity/type of pre-eclampsia and the associated trimester PRE-ECLAMPSIA

Please document the associated trimester and severity and/or type of pre-eclampsia.
   

Evidence

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E11 CDI2
Diagnoses:
Gestational diabetes
Pre-eclampsia
Premature labor
Perineal laceration
Infections relevant to pregnancy and delivery: chlamydia, CMV, GBS, gonorrhea, hepatitis B and C, HIV, listeria, rubella, syphilis, toxoplasmosis

Clinical signs and symptoms:
Premature rupture of membranes
Cervical effacement
Cervical dilatation

Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
40401*P     Pediatric notification: Documentation of bronchopulmonary dysplasia (age: < 28 days)        
40402P Pediatric: Documentation of chronic lung disease without documentation of the etiology of chronic lung disease Please specify the type of chronic lung disease.        

Evidence

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E11 CDI2
Diagnoses:
Gestational diabetes
Pre-eclampsia
Premature labor
Perineal laceration
Infections relevant to pregnancy and delivery: chlamydia, CMV, GBS, gonorrhea, hepatitis B and C, HIV, listeria, rubella, syphilis, toxoplasmosis

Clinical signs and symptoms:
Premature rupture of membranes
Cervical effacement
Cervical dilatation


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
2060001P Pediatric: Documentation of necrotizing enterocolitis without documentation of the stage of necrotizing enterocolitis Please document the stage of necrotizing entercolitis (NEC).    

Evidence

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Product Evidence
E11 CDI2



Rules

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AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
ComplicationsL&D-001P Pediatric: Documentation of nuchal cord without documentation of POA status NUCHAL CORD

Please document whether the nuchal cord was present on admission.
       

Evidence

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Product Evidence
E11 CDI2



Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
2200001P 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.        

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001123 Clinical evidence of blood loss anemia or recent surgery and lab evidence of drop in hemoglobin of 2 g/dL or more without documentation of acute blood loss anemia There is documentation or evidence of a drop in hemoglobin and a recent surgery or clinical evidence of low hemoglobin. Please document any associated diagnosis    
8000 Lab evidence of anemia and evidence of blood loss, transfusion, or gastrointestinal bleed (+/- clinical evidence of blood loss) without documentation of blood loss anemia LOW HGB AND HCT

There is evidence of low hemoglobin and hematocrit and documentation of blood loss and/or transfusion. Please document any associated diagnosis.
   
80014A Documentation of anemia without documentation of the type, acuity, and etiology of anemia (age: > 18 years) ANEMIA

Please document the etiology, type, and acuity of anemia, if known.
8003 Documentation or lab evidence of anemia (+/- clinical evidence of blood loss or transfusion) without documentation of the type or etiology of anemia BLOOD DISORDER

There is evidence of a blood disorder; please consider documenting the type.
8004   Lab evidence of anemia (+/- clinical evidence of blood loss or a transfusion) without documentation of the type of anemia
8005 Documentation of anemia (+/- clinical evidence of blood loss, a transfusion, or lab evidence of anemia) without documentation of the type of anemia ANEMIA - C

Please document the type of anemia.
Anemia-001 Documentation of anemia without documentation of pancytopenia or the acuity and type of anemia ANEMIA TYPE/ACUITY

Please document the type and acuity of anemia, if known.
Anemia-002 Documentation or lab evidence of anemia without documentation of the etiology, type, and acuity of anemia EVIDENCE/EXPLICIT MENTION OF ANEMIA

There is evidence of a blood disorder; please consider documenting the type, etiology, and acuity.
Anemia-004 Documentation or lab evidence of anemia (+/- evidence of blood loss or transfusion) without documentation of the type or etiology anemia BLOOD DISORDER - E

There is evidence of a blood disorder; please consider documenting the type.
Anemia-005 Documentation of anemia without documentation of the type, acuity, or etiology of anemia ANEMIA - B

Please document the etiology, type, and/or acuity of the anemia.

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Anemia

Clinical signs and symptoms:
Blood loss
 Adults (ages > 18): > 500 mL
 Children (ages <= 18): age & weight-based values
Gastrointestinal bleeding

Labs:
Low hematocrit:
 Adults (ages > 18): < 32%
 Children (ages <= 18): age-based values
Low hemoglobin:
 Adults (ages > 18): females < 12 g/dL, males < 13 g/dL
 Children (ages <= 18): age-based values

Medications and/or therapeutic treatments:
Transfusion

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51000862A Documentation of a bleed and an anticoagulation medication without documentation of whether the anticoagulant caused the bleed (age:>18 years) Bleeding and anticoagulation are documented. Please clarify whether these are causally related.  


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001242 Documentation of immunosuppressive medication or therapy and history of transplant without documentation of immunosuppressive status Immunosuppressive medication or therapy and transplant have been documented. Please document the patient's immune status.        
51001342A Evidence of immunosuppressant medication(s) or CAR T-cell therapy without documentation of immune status (age: >18 years) There is evidence of immunosuppressant treatment or CAR T-cells therapy. Please document the immune status.        


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001428P 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.    


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
8006 Documentation of neutropenia (+/- lab evidence of neutropenia) without documentation of the type or etiology of neutropenia NEUTROPENIA TYPE

Please document the type of neutropenia, if known.
     
8007*     Notification: Documentation of drug or chemotherapy induced neutropenia        
Anemia-003 Documentation or lab evidence of neutropenia and documentation of chemotherapy without documentation of the etiology of neutropenia CHEMOTHERAPY AND BLOOD DISORDER

There is documentation or evidence of a blood disorder and chemotherapy. Please clarify whether these are causally related.
     

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Agranulocytosis
Granulocytopenia
Neutropenia

Labs:
Neutropenia
 Neutrophil count: < 1,200
 Segmented neutrophil count: < 1,200
 Absolute neutrophil count (ANC): < 1,500

Medications and/or therapeutic treatments:
Anti-neoplastics


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
48003 Documentation or lab evidence of pancytopenia without documentation of the etiology of pancytopenia HEMATOLOGIC ABNORMALITY - ETIOLOGY

There is evidence of a blood disorder. Please document the corresponding condition and etiology, if known.
   
48006 Documentation or lab evidence of pancytopenia and documentation of a non-chemotherapy pancytopenia-inducing medication without documentation of drug-induced pancytopenia HEMATOLOGIC ABNORMALITY

Please confirm if there is a link between the drug mentioned and the documented hematologic abnormality.
   
48007 Documentation or lab evidence of pancytopenia and documentation of a stem cell or bone marrow transplant without documentation of pancytopenia HEMATOLOGIC ABNORMALITY - TRANSPLANT

There is evidence of a hematologic abnormality in the presence of a stem cell/bone marrow transplant, please document if known.
   
80012 Lab evidence of pancytopenia without documentation of pancytopenia LOW HGB, PLATELETS, AND WBC

There is evidence of low hemoglobin, platelets, and white blood cell count. Please document any associated diagnosis.
   
80013A Lab evidence of thrombocytopenia without documentation of thrombocytopenia or pancytopenia (age: > 18 years) LOW PLATELETS

There is evidence of low platelets. Please document any associated diagnosis.
   
80015A Lab evidence of pancytopenia without documentation of pancytopenia (age: > 18 years) BLOOD DISORDER - D

There is evidence of low hemoglobin, platelets, and ANC. Please document any associated diagnosis.
   
8008 Documentation or lab evidence of pancytopenia and documentation or medication evidence of chemotherapy without documentation of chemotherapy-induced pancytopenia CHEMOTHERAPY AND PANCYTOPENIA

There is documentation or evidence of a blood disorder and chemotherapy. Please clarify whether these are causally related.
   

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Aplastic anemia
Pancytopenia
Pure red cell aplasia

Labs:
Low absolute neutrophil count
 Adults (ages > 18): < 1,500/uL
 Children (ages <= 18): < 1,500/uL
Low hemoglobin:
 Adults (ages > 18): females < 12 g/dL, males < 13 g/dL
 Children (ages <= 18): age-based values
Low platelets
 Adults (ages > 18): platelet count < 150,000
 Children (ages <= 18): platelet count < 150,000
Low white blood cell count
 Adults (ages > 18): < 4,000/uL
 Children (ages <= 18): < 4,500/uL

Medications and/or therapeutic treatments:
Anti-inflammatories
Anti-neoplastics
Anti-thyroid
Antivirals
Atypical anti-psychotics
Bone marrow transplant
Immunomodulators
Immunosuppressants
Stem cell transplant
Thionamide


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
PedAnemia-003P 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.
   


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
42001 Documentation of sickle cell anemia and clinical evidence of acute chest syndrome without documentation of acute chest syndrome There is evidence of respiratory symptoms, chest pain, infiltrate on chest x-ray and/or exchange transfusion, and documentation of sickle cell anemia. Please document any associated diagnosis.    
42002 Documentation of sickle cell anemia and lab or clinical evidence of splenic sequestration without documentation of splenic sequestration There is evidence of low or decrease in hemoglobin, elevated reticulocyte count, splenomegaly, and/or transfusion, and documentation of sickle cell anemia. Please document any associated diagnosis.    

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Acute chest syndrome
Sickle cell anemia
Sickle cell crisis

Clinical signs and symptoms:
Chest pain
Cough
Dyspnea
Fever
Hypoxia
Pulmonary infiltrates
Splenomegaly
Sputum production
Temperature: > 101 F / 38.3 C

Labs:
Hemoglobin: < 5 g/dL
Reticulocyte count: > 100,000

Medications and/or therapeutic treatments:
Transfusion

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
45001 Documentation of acute myeloid leukemia without documentation of subtype/grade ACUTE MYELOID LEUKEMIA - B

Please document the subtype of AML, if known.
 
45002 Documentation of chronic myeloid leukemia without documentation of BCR/ABL status CHRONIC MYELOID LEUKEMIA

Please document the CML BCR/ABL result (i.e., positive, negative), if known.
   
45004 Documentation of leukemia (+/- documentation of hospice or evidence of chemotherapy, radiation therapy, or antineoplastic therapy) without documentation of relapse, remission, new diagnosis or active status LEUKEMIA

Please document the leukemia status (e.g., new diagnosis, relapse, remission, never achieved remission).
 
51000422 Documentation of acute lymphocytic leukemia without documentation of relapse, remission, new diagnosis or active status ACUTE LYMPHOCYTIC LEUKEMIA - B

Please document the status of acute lymphocytic leukemia (e.g., relapse, remission, never achieved remission, or new diagnosis).
   
65001 Documentation of chronic lymphocytic leukemia without documentation of relapse, remission, new diagnosis, or active status CHRONIC LYMPHOCYTIC LEUKEMIA

Please document the CLL status (e.g., new diagnosis, relapse, remission, never achieved remission).
   

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Leukemias

Medications and/or therapeutic treatments:
Anti-neoplastics
Hospice care
Palliative care
Radiation therapy


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
47001 Documentation of Hodgkin lymphoma without documentation of the subtype of Hodgkin lymphoma HODGKIN'S LYMPHOMA

Please document the subtype of Hodgkin's lymphoma, if known.
 
47002 Documentation of follicular lymphoma without documentation of subtype/grade of follicular lymphoma FOLLICULAR LYMPHOMA

Please document the grade of follicular lymphoma, if known.
 
47003 Documentation of lymphoma without documentation of the type of lymphoma LYMPHOMA

Please document the type of lymphoma, if known.
 
47004 Documentation of lymphoma without documentation of site of lymphoma LYMPHOMA - SITE

Please document the site of lymphoma, if known.
 

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Leukemias

Medications and/or therapeutic treatments:
Anti-neoplastics
Hospice care
Palliative care
Radiation therapy


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
60302 Documentation of metastatic disease without documentation of the site of metastatic disease METASTATIC DISEASE

Please document the site(s) of metastatic disease.
 

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Leukemias

Medications and/or therapeutic treatments:
Anti-neoplastics
Hospice care
Palliative care
Radiation therapy


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
68001 Documentation of multiple myeloma without documentation of relapse, remission, new diagnosis, or active status MULTIPLE MYELOMA

Please document the multiple myeloma status (e.g., relapse, remission, new diagnosis, or active status).
   

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Leukemias

Medications and/or therapeutic treatments:
Anti-neoplastics
Hospice care
Palliative care
Radiation therapy


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51001185 Documentation of carcinoid tumor without documentation of whether it is benign or malignant Please document the type of carcinoid tumor, if known.  
51001223 Documentation of neuroendocrine carcinoma or tumor without documentation of specificity (e.g., low/high grade, poorly/well differentiated, small cell or large cell) Neuroendocrine carcinoma or tumor has been documented. Please document specificity of carcinoma/tumor (e.g., low/high grade, poorly/well differentiated, small cell or large cell).    

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
51000886 Documentation of a positive candida auris culture (+/- documentation of cadida auris carrier) without documentation of the presence or absence of candida auris infection and site There is documentation of positive candida auris culture. Please document any associated diagnosis and site.

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Candida auris carrier
Candida auris infection

Labs:
Candida auris: positive


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
34001 Documentation of viral meningitis without documentation of the causative organism VIRAL MENINGITIS

Please document the causative organism of viral meningitis, if known.
     
34002 Documentation of bacterial meningitis without documentation of the causative organism BACTERIAL MENINGITIS

Please document the causative organism of bacterial meningitis, if known.
     
34003 Documentation of meningitis (+/- documentation of an organism or the causative organism of meningitis) without documentation of the type of meningitis MENINGITIS

Please document the type of meningitis and causative organism, if known.
 


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
35001 Documentation of Staphylococcus aureus (+/- evidence of MRSA or MSSA) without documentation of MSSA or MRSA infection or organism STAPH. INFECTION

Please document whether the S. aureus infection is MRSA or MSSA.
 


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
16003 Documentation of urosepsis (+/- evidence of organism or sepsis due to an organism) without documentation of sepsis due to urinary tract infection UROSEPSIS

There is documentation of urosepsis. Please document a more specific diagnosis.
16006*     Notification: Documentation that sepsis, SIRS, or septic shock was present on admission        
16008 Documentation of sepsis, SIRS, or septic shock without documentation of present on admission status SEPSIS POA

Please document whether sepsis was present on admission.
   
16009 Documentation of sepsis due to urinary tract infection without documentation of the site of urinary tract infection, whether hematuria is present, and the causative organism of sepsis SEPSIS DUE TO UTI

There is documentation of sepsis due to UTI, please document causative organism, site and presence of hematuria, if possible.
   
16010 Clinical and lab evidence of sepsis (+/- clinical or lab evidence of acute organ dysfunction, documentation of acute organ dysfunction or a causative organism, or antibiotic evidence) without documentation of sepsis, SIRS, or septic shock UNSPECIFIED CLINICAL CONDITION

There is evidence of abnormal temperature and WBC count and other clinical and/or laboratory abnormalities. Please document any associated diagnosis.
16012*     Notification: Documentation of sepsis or SIRS and documentation of a urinary device, vascular device, graft, or orthopedic device        
16013*     Notification: Documentation of sepsis or SIRS (+/- clinical or lab evidence of sepsis)        
16015   Documentation of urinary tract infection as present on admission without documentation of a urinary device URINARY TRACT INFECTION POA

There is documentation of a urinary tract infection that was present on admission and a urinary device. Please clarify whether these are causally related.
     
16019 Documentation of sepsis without documentation of the causative organism of sepsis or bacteremia SEPSIS - ORGANISM

Please document the causative organism of sepsis, if known.
   
16020*     Notification: Documentation of transfusion and sepsis        
16021*     Notification: Documentation of bacteremia        
16022   Documentation of urinary tract infection without documentation of urinary device or whether urinary device caused the urinary tract infection UTI - URINARY DEVICE

There is documentation of a urinary tract infection. Please document the etiology of the UTI.
 
16027 Documentation of a central line and sepsis or SIRS without documentation of the relationship between the central line and sepsis or SIRS SEPSIS - CENTRAL LINE

There is evidence of a central line and documentation of sepsis. Please clarify whether these are causally related.
   
16028 Documentation of sepsis without documentation of the etiology of sepsis SEPSIS - CAUSE

Please document the etiology of sepsis, if known.
   
16030 Documentation of severe sepsis without documentation of the relationship between sepsis and organ dysfunction or disease SEVERE SEPSIS

Please document any organ dysfunction associated with severe sepsis.
   
16033 Documentation of bacteremia without documentation of the presence or absence of sepsis, SIRS, or septic shock BACTEREMIA

There is documentation of bacteremia. Please document any associated systemic diagnosis, if applicable.
 
16035 Documentation of sepsis or SIRS without clinical or lab evidence of sepsis or SIRS SEPSIS - CLINICAL INDICATORS - RULE A - B

SIRS/Sepsis was documented, please document supporting evidence, if known.
   
51000001*     Notification: Documentation of central line removal and catheter tip culture        
51000323 Clinical or lab evidence of sepsis without documentation of the presence or absence of sepsis, SIRS, or septic shock UNSPECIFIED CLINICAL CONDITION - C

There is evidence of abnormal temperature and/or WBC count, as well as additional clinical and/or lab evidence of organ dysfunction. Please document the diagnosis associated with this evidence as appropriate.
   
51000707*   Notification: Documentation of sepsis and no documentation of IV fluid administration There is documentation of sepsis. Please document administration of an IV fluid bolus of 30 ml/kg, based on patient weight recommendation, OR document specification for not administering recommended IV fluid bolus amount.        
51001287A Documentation of sepsis in the emergency department without documentation of sepsis in the inpatient documentation (age >18 years) Sepsis is documented in the emergency department but has not been documented after admission. Please clarify the presence or absence of the diagnosis.        
Sepsis-001 Clinical and lab evidence of sepsis (+/- clinical or lab evidence of acute organ dysfunction, documentation of acute organ dysfunction or a causative organism, or antibiotic or vasopressor evidence) without documentation of sepsis, SIRS, or septic shock UNSPECIFIED CLINICAL CONDITION - B

There is evidence of abnormal temperature and WBC count and other clinical and/or laboratory abnormalities. Please document any associated diagnosis.
Sepsis-002 Documentation of infection and clinical and lab evidence of sepsis (+/- clinical evidence of organ dysfunction, documentation of causative organism, or antibiotic evidence) without documentation of sepsis, SIRS, or severe sepsis INFECTIOUS DISORDER - B

There is evidence of abnormal temperature and WBC count, other clinical and/or laboratory abnormalities, and documentation of an infection. Please document any associated diagnosis.
 
Sepsis-004 There is documentation of burn sepsis without documentation of localized infection or systemic sepsis. (Canada) BURN SEPSIS

There is documentation of burn sepsis. Please clarify whether the patient has systemic sepsis or a local infection.
       
Sepsis-005 Documentation of sepsis and clinical or lab evidence of sepsis without documentation of whether sepsis was present on admission (age: >= 18 years) PSI 13 SEPSIS

Please document whether sepsis was present on admission.
   
Sepsis-007 Documentation of sepsis due to urinary tract infection without documentation of the site of urinary tract infection and causative organism of sepsis SEPSIS DUE TO UTI - B

Please document the causative organism and site of UTI, if known.
   
Sepsis-008A Documentation of infection and clinical or lab evidence of sepsis (+/- clinical or lab evidence of organ dysfunction or documentation of altered mental status or encephalopathy) without documentation of sepsis, SIRS, or severe sepsis (age: > 18 years) INFECTIOUS DISORDER

There is evidence of abnormal vital signs and/or WBC count, and documentation of an infection. Please document any associated diagnosis.
 
Sepsis-009 Documentation of sepsis without documentation of the causative organism of sepsis or bacteremia (age: > 3 months) SEPSIS-ORGANISM

Please document the causative organism of sepsis, if known.

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Acute kidney injury (AKI)
Burn: chemical, electrical, radiation, thermal
Encephalopathy
Gastrointestinal obstruction
Heart failure
Hepatic failure
Hypotension
Hypothermia
Hypoxia
Hyperglycemia
Infection: abscess, bacteremia, cellulitis, peritonitis
Leukocytosis
Myocardial infarction
Organ dysfunction
Renal failure
Respiratory failure
Tachypnea
Tachycardia
Traumatic injury: crushing, fall, gunshot, motor vehicle

Clinical signs and symptoms:
Altered mental status
Fever
High body temperature: > 101.0 Fahrenheit or > 38.3 Celsius
High heart rate:
 Adults (ages > 18): > 90 beats/min
 Children (ages <= 18): age-based values
Low body temperature: < 96.8 Fahrenheit or < 36.0 Celsius
Low heart rate: age-based values (children only)
Mean arterial pressure (MAP): < 65 mmHg (adults only)
Oxygen saturation: < 85%
Respiratory rate:
 Adults (ages > 18): > 20 breaths/min
 Children (ages <= 18): age-based values
Sequential organ failure assessment (SOFA) score
Systolic blood pressure (SBP)
 Adults (ages > 18): < 90 mmHg
 Children (ages <= 18): age-based values

Labs:
Activated partial thromboplastin time (aPTT): > 60 seconds (without anticoagulants)
Bands: >10%
Creatinine: > 2 mg/dL (without renal failure)
Glucose: > 120 mg/dL (without diabetes)
International normalized ratio (INR): < 1.5 (without anticoagulants)
Lactate: > 2 mmol/L
Partial pressure of carbon dioxide (PaCO2): < 32 mmHg
Platelet count: < 100,000
Total bilirubin: > 2 mg/dL
White blood cell (WBC) count:
 Adults (ages > 18): < 4,000 or > 12,000
 Children (ages <= 18): age-based values
White blood cell (WBC) left shift

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



Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
Sepsis-006 Documentation of major surgery, trauma, burn, or pancreatitis and clinical or lab evidence of SIRS (+/- clinical or lab evidence of non-infectious SIRS) without documentation of the presence or absence of non-infectious SIRS UNSPECIFIED CLINICAL CONDITION - D

There is evidence of abnormal temperature and WBC count and other clinical and/or laboratory abnormalities. Please document any associated diagnosis.
   

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12002 Documentation of unresponsiveness or altered mental status without documentation of etiology MENTAL STATUS CHANGE - ETIOLOGY

Please document the etiology of altered mental status or unresponsiveness, if known.
       
12016   Documentation of unresponsiveness without documentation of the level of unresponsiveness        
12021 Documentation of altered mental status without documentation of the etiology and specificity of altered mental status ALTERED MENTAL STATUS

Please document **specificity** and **etiology** of altered mental status, if possible.
150003 Documentation of altered mental status without documentation of the level of altered mental status (coma, locked-in syndrome, or stupor) MENTAL STATUS CHANGE

Please specify level of altered mental status (stupor, coma, or locked-in syndrome, or something else), if possible.
 
AltMentalStatus-001 Documentation of altered mental status, unresponsiveness or encephalopathy without documentation of the level of altered mental status/unresponsiveness or the type of encephalopathy ALTERED MENTAL STATUS - B

Please document **the level of AMS, level of unresponsiveness or type of encephalopathy,** if possible.

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Cognitive disorder
Encephalopathy

Clinical signs and symptoms:
Altered mental status
Unresponsiveness


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
12027 Documentation of a cognitive disorder without documentation of the type of cognitive disorder COGNITIVE DISORDER

Please document type of cognitive disorder.
 
12028 Documentation of a cognitive disorder without documentation of the etiology of the cognitive disorder COGNITIVE DISORDER - ETIOLOGY

Please document **etiology** of cognitive disorder, if possible.
 
5060007 Documentation of an eating disorder without documentation of the type of eating disorder EATING DISORDER

Please document the type of eating disorder.
   
5060008 Documentation of bipolar disorder without documentation of the severity and type of bipolar disorder BIPOLAR DISORDER

Please document the type and severity of bipolar disorder.
   
5060010 Documentation of an anxiety disorder without documentation of the acuity and type of anxiety disorder ANXIETY DISORDER

Please document the type and acuity of anxiety disorder.
     
5060012 Documentation of obsessive compulsive disorder without documentation of any associated conditions or the cause of obsessive compulsive disorder OCD

Please document any conditions associated with OCD.
       
5060014*   Notification: Documentation of one or more antipsychotic medications MULTIPLE ANTIPSYCHOTICS

Multiple antipsychotic medications have been documented. Please ensure that this is intended and update documentation accordingly.
       
5060015 Documentation of suicidal ideation or history of suicidal ideation without documentation of length of time of the suicidal ideation SUICIDAL IDEATION

Please document the length of time of suicidal ideation, if known.
     
5060021 Documentation of dementia (+/- documentation of behavioral disturbance) without documentation of the type of dementia DEMENTIA

Please document the type of dementia.
 
51000462 Documentation of vascular dementia without documentation of type of vascular dementia VASCULAR DEMENTIA

Please document the type of vascular dementia, if known.
   

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Anxiety
Autism
Bipolar disorder
Dementia
Depression
Eating disorder
Obsessive-compulsive disorder
Schizophrenia

Clinical signs and symptoms:
Agitation
Anger
Delirium
Delusions
Hallucinations
Paranoia
Psychosis
Suicidal ideation

Medications and/or therapeutic treatments:
Antidepressants
Antipsychotics


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
40600P Pediatric: Documentation of a developmental delay without documentation of the type of development delay DEVELOPMENTAL DELAY

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

Please document the type of autism.
   
5060006P 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**.
     


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
40300 Documentation of an intellectual disability without documentation of the severity of intellectual disability INTELLECTUAL DISABILITY

Please document the severity of intellectual disability (i.e., mild, moderate, severe, or profound).
     


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
5060002*   Mention of bipolar disease or major depression is present SUBSTANCE USE ASSESSMENT

Please consider an alcohol or chemical substance use assessment with a diagnosis of bipolar disease and major depression.
       
5060004*   Mention of clinical depression is present FOLLOW-UP PLAN

Clinical depression has been documented. Please consider a follow-up plan.
       
5060011 Documentation of depression without documentation of the acuity, occurrence, and type of depression DEPRESSION

Please document the type, acuity and occurrence of depression.
 
5060016 Documentation of depression or history of depression with medication evidence of an antidepressant without documentation of episodicity, status, and severity of depression DEPRESSION - B

Please document the episode, severity and status of the depression.
 
51001302A Documentation of antidepressant treatment (+/- severity or episode of depression/depressive disorder) without documentation of depression or depressive disorder There is documentation of anti-depressant treatment. Please document the associated condition.  


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
5060003*   Mention of schizophrenia or bipolar disorder and antipsychotic medication is present CARDIOVASCULAR HEALTH SCREENING

Please consider a cardiovascular health screening for a diagnosis of schizophrenia or bipolar disorder receiving an antipsychotic medication.
       
5060009 Documentation of schizophrenia (+/- evidence of schizophrenia) without documentation of the type of schizophrenia SCHIZOPHRENIA

Please document the type of schizophrenia.
   

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
5060018 Documentation of CIWA and alcohol abuse (+/- medication evidence of IV Lorazepam) without documentation of alcohol dependence and withdrawal ALCOHOL ABUSE

There is evidence of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) and documentation of alcohol abuse. Please document whether or not alcohol dependency and/or withdrawal are present.
   
5060019 Documentation of alcohol withdrawal without documentation of alcohol abuse, alcohol dependence, or severe alcohol use disorder ALCOHOL WITHDRAWAL

Alcohol withdrawal was identified in the documentation, please document if there is alcohol dependence or alcohol severe use disorder, if known.
   


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
5060017 Documentation of a nicotine patch without documentation of nicotine dependence and withdrawal NICOTINE PATCH

Please consider documenting if **nicotine dependence** and **withdrawal** are present.
     


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
5060020 Documentation of substance abuse without documentation of substance type, status of abuse, and type of dependency SUBSTANCE ABUSE

Please document the type of substance, dependency status, and active or remission status of the substance abuse.
 

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
14006 Documentation of an open fracture of a long bone without documentation of Gustilo classification GUSTILO CLASSIFICATION

Please document the Gustilo classification of the open long bone fracture.
 
14007 Documentation of fracture without documentation of the laterality of the fracture FRACTURE LATERALITY

Please document the laterality of the fracture.
   
14008*   Notification: Documentation of an extremity fracture SPLINT NOTE

There is evidence of an extremity fracture; please make sure that the 'splint note' is complete.
       
14011 Documentation of a radial fracture (+/- documentation of radiologic studies of the radius) without documentation of the laterality, location, pattern, or type of radial fracture RADIAL FRACTURE

Please document the location, type, pattern, and laterality of radial fracture, if known.
14013 Documentation of a tibial fracture (+/- documentation of radiologic studies of the tibia) without documentation of the laterality, pattern, site, and type of tibial fracture TIBIAL FRACTURE

Please document the location, type, pattern, and laterality of tibial fracture, if known.
 
14018 Documentation of a radial fracture (+/- documentation of radiologic studies of the radius) without documentation of the presence or absence of an ulnar fracture RADIAL/ULNAR FRACTURE

There is documentation of a radial fracture. Please document whether or not there are any other associated fractures.
   

Evidence

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2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Bone cyst
Bone fragment
Cancer/malignancy
Flail chest
Fracture type: avulsion, bowing, burst, chip, closed, compression, crush, dislocation, fragility, healed, impacted, insufficiency, malunion, open, pathological, stress, subluxation, wedge
Ligament avulsion
Metabolic bone disease: osteomalacia, osteoporosis, rickets
Osteitis
Osteochondritis
Osteomyelitis
Osteopenia
Renal osteodystrophy
Vertebral collapse

Medications and/or therapeutic treatments:
Bone reabsorption inhibitors
Calcium carbonate
Cholecalciferol
RANKL inhibitors
Selective estrogen receptor modulators

Diagnostic procedures and/or procedure findings:
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Radiography (X-ray)

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
20008 Documentation of a laceration or wound and repair (+/- evidence of repair complexity) without documentation of the laceration or wound measurement and complexity of repair LACERATION/WOUND REPAIR

A laceration or wound repair was documented. Please document the wound measurement(s) and complexity of repair.
       

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
20018 Documentation of a burn without documentation of the body surface area, degree, laterality, site, causative agent and present on admission status of the burn BURN

Please document the degree, site, laterality, etiology, body surface area, and POA status of the burn.

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
28000 Clinical evidence of functional quadriplegia or quadriparesis without documentation of functional quadriplegia or quadriparesis (age: > 5 years) DEPENDENCY OF CARE - B

There is evidence of complete dependency of care without spinal cord injury, please document a corresponding condition, if applicable.
 
28001 Documentation of functional quadriplegia or quadriparesis without documentation of the etiology of functional quadriplegia or quadriparesis Please document the etiology of the functional quadriplegia/quadriparesis, if known.    
28003 Documentation of functional quadriplegia or quadriparesis without evidence of functional quadriplegia or quadriparesis Functional quadriplegia/quadriparesis was documented, please document supporting evidence, if known.    


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
2004003 Documentation of hospice or palliative care qualifiers without documentation of hospice or palliative care HOSPICE/PALLIATIVE CARE

There is documentation of Hospice/Palliative care qualifiers (poor prognosis, end of life, comfort measures, etc) if applicable, please document appropriately.
       

Evidence

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2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Clinical signs and symptoms:
Prognosis status

Medications and/or therapeutic treatments:
Comfort care management
Terminal care management

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
58001 Documentation of HIV positive (+/- lab evidence of CD4 or RNA or medication evidence of HIV or documentation of HIV-related conditions) without documentation of HIV status HIV

There is documentation of HIV positive. Please specify HIV status as symptomatic, asymptomatic, HIV disease/AIDS, or unable to determine.
 

Evidence

1Engage One
2CDI Collaborate and 360 Encompass Evidence Sheets
Product Evidence
E11 CDI2
Diagnoses:
Candidiasis
Cytomegalovirus (CMV) infection
Cryptococcosis
HIV: acute infection, asymptomatic, HIV disease (AIDS)
Kaposi's sarcoma
Mycobacterial infection
Pneumocystosis jirovecii pneumonia

Labs:
CD4+ count, percentage
HIV viral load

Medications and/or therapeutic treatments:
Anti-retrovirals

Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
27000*     Notification: Documentation of an MCC and/or CC medical condition        


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
4000200 Clinical, medication, and procedure evidence of critical care services without documentation of time spent providing critical care CRITICAL CARE

There is evidence of one or more diagnoses and interventions related to critical care services. Please document the length of time critical care services were provided, if appropriate.
       
40700 Evidence of medical non-compliance without documentation of medical non-compliance MEDICAL NON-COMPLIANCE

There is evidence of medical non-compliance, please document medical non-compliance if it is present.
     
51000763*     Notification: Documentation in a surgical note of a specimen sent for analysis        
SpecialReqWMC-002*     Notification: Documentation of 'in the setting of'        


Rules

1Engage One  2CDI Collaborate and 360 Encompass Evidence Sheets
AAdult Only  PPediatric Only
*Clinical Notification
Code Product Rule Physician Message Risk Classification
E11 CDI2 CC MCC HCC MS-DRG
2004001*     Notification: Documentation of an unspecified diagnosis in the impression or assessment and plan section