To return to the Fluency documentation site, use your browser’s back button

NLU Content

Content available as of NLU version 3.107

This page lists the clinical notifications, opportunities, and physician messages (herein all referred to as "opportunities") 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 browse by category and condition below.

The opportunities are listed by categories, aligned with the Major Diagnostic Categories (MDC), and further specified into conditions within each category. For each condition listed, a table lists the following information for each opportunity:

Code: A machine-readable unique identifier for the opportunity. An * indicates the opportunity is a Clinical Notification.
Product: The product in which the opportunity is used. The "E1" column represents 3M Engage One, and the "CDI" column includes 360 Encompass and CDI Collaborate.
Opportunity: A translation of the triggers, missing information, and resolution.
Physician Message: The nudge message text the physician receives when the opportunity is triggered. The nudge title is uppercase with the message beneath it.
Risk Classification: A checkmark in any of the CC, MCC, HCC, or MS-DRG columns, indicates that if the requirements of the opportunity are met, it MAY result in a diagnosis that qualifies for that risk adjustment category. Please note, an ICD-10 diagnosis code will not be generated, and only in a few instances will MEAT criteria be fulfilled. This is only to indicate that a resultant diagnosis from a fulfilled opportunity MAY qualify.

Available opportunities are displayed under each condition. Examples of supporting evidences that MAY trigger or resolve the opportunities can be seen as hover hints. The hover hints do not contain an all-inclusive list and are only meant to provide a concise example of the opportunity's evidence.

To view a guide for navigating this page, click here

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

Categories and Conditions

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
150022 Triggering evidence: Documentation of increased intracranial pressure (ICP) OR mass effect of brain OR midline shift of brain : • Compression of brain • Raised intracranial pressure AND (+/-) clinical, medication OR treatment evidence of increased intracranial pressure: • Diuretic • Phenobarbital • Craniectomy • Drainage of cerebrospinal fluid • Ventriculostomy Satisfying evidence: Documentation of the etiology of increased intracranial pressure (ICP) OR mass effect of brain OR midline shift of the brain: • Cerebral edema • Brain stem herniation • Encephalopathy • Head trauma • Hydrocephalus • Intracranial mass	✔	✔	Documentation of increased ICP or mass effect or midline shift of brain (+/- clinical, medication, or treatment evidence of increased ICP) without documentation of the etiology of increased ICP or mass effect or midline shift of brain	INCREASED INTRACRANIAL PRESSURE Please document the etiology of increased ICP or mass effect or midline shift of brain.		✔	✔	✔
51000842^R Triggering evidence: Radiology evidence of midline shift or mass effect of the brain AND Evidence of treatment of elevated intracranial pressure: • Diuretics • Decadron • Phenobarbital • Craniectomy • Drainage of cerebrospinal fluid • Ventriculostomy Satisfying evidence: Documentation of mass effect or midline shift of the brain: • Midline shift of the brain • Mass effect due to brain mass	✔	✔	Radiologic evidence of midline shift or mass effect and treatment evidence of elevated ICP without documentation of midline shift or mass effect	UNSPECIFIED CLINICAL CONDITION-L The radiology report contains evidence of a brain condition and there is evidence of treatment of elevated intracranial pressure. Please document any associated diagnosis.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
40901 Triggering evidence: Documentation of cerebral palsy Satisfying evidence: Documentation of the type of cerebral palsy: • Cerebral palsy • Congenital flaccid paralysis • Congenital paraplegia	✔	✔	Documentation of cerebral palsy without documentation of the type of cerebral palsy	CEREBRAL PALSY Please document the type of cerebral palsy.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51002802 Triggering evidence: Documentation of a cranial OR nasal procedure: • Including but not limited to: • Transsphenoidal approach • Excision of pituitary • Carniofacial procedures • Nasal septoplasty AND clinical evidence of cerebrospinal fluid leak: • Metallic taste • Loss of sense of smell • Nasal discharge Satisfying evidence: Documentation of a cerebrospinal fluid leak	✔	✔	Documentation of a cranial or nasal procedure and clinical evidence of a cerebrospinal fluid leak without documentation of a CSF leak	UNSPECIFIED CLINICAL CONDITION - K There is documentation of a cranial or nasal procedure and clinical evidence of nasal drainage, ansomia or metallic taste. Please document any assoicated daignosis.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
150001 Triggering evidence: Documentation of stroke : • Cerebrovascular infarction • Hemorrhagic cerebral infarction • Paralytic stroke AND Documentation of a paresis OR plegia : • Hemiplegia • Monoplegia • Hemiparesis • Left/right sided weakness (+/-) Clinical evidence of stroke: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of the affected side as dominant OR nondominant: • Hemiplegia of dominant side • Hemiplegia of nondominant side • Monoplegia of dominant side • Monolplegia of non dominant side	✔	✔	Documentation of a stroke and a paresis or plegia (+/- clinical evidence of stroke) without documentation of the affected side as dominant or nondominant	PLEGIA/PARESIS Please document the dominance of the side affected by the -plegia or -paresis.	✔
150002 Triggering evidence: Documentation of stroke: • Cerebrovascular infarction • Hemoragic cerebral infarction • Paralytic stroke AND MIN,2 documentation of 'unresponsiveness' : • Unresponsiveness • Unconscious • Disturbance of consciousness (+/-) Clinical evidence of stroke: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of the level of responsiveness: • Including but not limited to: • Delirium • Coma • Dementia • Stupor • Obtundation	✔	✔	Documentation of stroke and unresponsiveness (+/- clinical evidence of stroke) without documentation of the level of unresponsiveness (stupor, coma, or locked-in syndrome)	LEVEL OF RESPONSIVENESS Please document the level associated with responsiveness, if known.		✔	✔	✔
150004 Triggering evidence: Documentation of stroke OR cerebral ischemia : • Cerebrovascular infarction • Hemoragic cerebral infarction • Paralytic stroke • Ischemic stroke (+/-) Evidence of the type of stroke: • Embolus • Hemorrhage • Infarct • Ischemia • Stenosis • Thrombus Satisfying evidence: Documentation of the type of stroke: • Thrombotic stroke • Ischemic stroke • Occlusive stroke • Embolic stroke • Hemorrhagic stroke	✔	✔	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.	✔	✔	✔	✔
150005 Triggering evidence: Documentation of stroke: • Cerebrovascular infarction • Hemoragic cerebral infarction • Paralytic stroke (+/-) clinical evidence of stroke: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of residual hemiparesis: • Hemiplegia • Hemiparesis • Monoparesis • Monopleagia • Paralytic syndrome • Paresis of the limb	✔	✔	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 Triggering evidence: Documentation of brain hemorrhage (+/-) clinical evidence of brain hemorrhage: • Including but not limited to: • Headache • Loss of consciousness • Nausea • Vertigo • Seizure Satisfying evidence: Documentation of the type of brain hemorrhage: • Including but not limited to: • Intracerebral hemorrhage • Intraventricular hemorrhage • Epidural hemorrhage • Subdural hemorrhage • Subarachnoid hemorrhage	✔	✔	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.	✔	✔		✔
150013 Triggering evidence: Documentation of stroke (+/-) clinical evidence of stroke : • Including but not limited to: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of sequela of stroke : • Including but not limited to: • Aphasia • Apraxia • Ataxia • Dysarthria • Hemiparesis • Weakness	✔	✔	Documentation of stroke (+/- clinical evidence of stroke) without documentation of sequela of stroke	STROKE CONDITIONS There is documentation of stroke. Please document any residual conditions, if applicable.	✔			✔
150014 Triggering evidence: Documentation of stroke OR cerebral infarction (+/-) clinical evidence of stroke: • Including but not limited to: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of the site of the stroke OR cerebral infarction: • Anterior cerebral circulation hemorrhagic infarction • Brainstem stroke syndrome • Cerebellar stroke syndrome • Posterior cerebral circulation hemorrhagic infarction • Thrombosis od intracrantial venous sinus	✔	✔	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.		✔
150026^A Triggering evidence: Documentation of stroke: • Cerebrovascular infarction • Hemoragic cerebral infarction • Paralytic stroke AND evidence of behavioral disturbances: • Altered mental status • Anxiety • Delirium • Depressive disorder • Hallucination • Stupor Satisfying evidence: Documentation of vascular dementia OR documentation of the etiology of the behavioral disturbances: • Including but not limited to: • Altered mental status • Anxiety • Delirium • Depressive disorder • Hallucination • Stupor • Any physician documented cause of behavioral disturbances • Idiopathic • Multifactorial	✔	✔	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* Triggering evidence: Documentation of stroke : • Cerebrovascular infarction • Hemorrhagic cerebral infarction • Paralytic stroke AND documentation of paresis OR plegia : • Hemiparesis • Hemiplegia • Monoparesis • Monoplegia • Muscle weakness • Paralytic syndrome AND documentation of decubitus ulcer		✔	Notification: Documentation of stroke, paresis or plegia, and decubitus ulcer
Cerebrovascular-001 Triggering evidence: Documentation of acute stroke Satisfying evidence: Documentation the presence or absence of coma AND documentation of NIHSS score	✔	✔	Documentation of acute stroke without documentation of NIHSS score and presence or absence of coma	ACUTE STROKE There is documentation of acute stroke. Please document NIHSS score and presence or absence of coma, if known.				✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
OtherNervous-002 Triggering evidence: Evidence of Glasgow coma score < 9 (+/-) clinical evidence of coma : • Absent corneal reflexes • Decerebrate posture • Decorticate posture • Fixed dilation of pupil • No pupillary reaction to light • Persistent vegetative state • Unconscious/ Unresponsive AND NO documentation of drug-induced coma Satisfying evidence: Documentation of coma	✔	✔	Evidence of Glasgow coma score < 9 (+/- clinical evidence of coma) without documentation of coma	LOW GCS There is evidence of Glasgow coma score < 9. Please document any associated diagnosis.		✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
150011 Triggering evidence: Documentation of closed head injury OR traumatic brain injury: • Closed head injury (CHI) • Traumatic brain injury (TBI) • Concussion • Contusion • Diffuse axonal injury • Intracranial hematoma (+/-) Clinical evidence of concussion: • Nausea and vomiting • Altered mental status • Dizziness • Persistent headache Satisfying evidence: Documentation of concussion: • Brain injury with concussion • Brain stem laceration with concussion • Cerebellar contusion with concussion • Open head injury with concussion	✔	✔	Documentation of closed head injury or traumatic brain injury (+/- clinical evidence of concussion) without documentation of concussion	HEAD INJURY There is documentation of closed head injury. Please document any associated diagnosis.	✔		✔	✔
150018 Triggering evidence: Documentation of loss of consciousness (LOC) Satisfying evidence: Documentation of the duration of loss of consciousness (LOC)	✔	✔	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 Triggering evidence: Documentation of concussion : • Brain injury with concussion • Brain stem laceration with concussion • Cerebellar contusion with concussion • Open head injury with concussion (+/-) evidence of LOC unspecified duration (+/-) evidence of LOC with >=30 min time element Satisfying evidence: Documentation of initial, subsequent OR sequela visit	✔	✔	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.	✔		✔	✔
150020 Triggering evidence: Documentation of concussion : • Brain injury with concussion • Brain stem laceration with concussion • Cerebellar contusion with concussion • Open head injury with concussion AND documentation of loss of consciousness (LOC) Satisfying evidence: Documentation of the duration of loss of consciousness (LOC): • Loss of consciousness (LOC)	✔	✔	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 Triggering evidence: Documentation of concussion: • Brain injury with concussion • Brain stem laceration with concussion • Cerebellar contusion with concussion • Open head injury with concussion Satisfying evidence: Documentation of the presence or absence of loss of consciousness (LOC)	✔	✔	Documentation of concussion without documentation of the presence or absence of loss of consciousness	CONCUSSION - B There is documentation of concussion. Please document any associated diagnosis.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12012^P Triggering evidence: Documentation of hypoxic ischemic encephalopathy Satisfying evidence: Documentation of the severity of the hypoxic ischemic encephalopathy: • Mild • Moderate • Severe	✔	✔	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.	✔	✔		✔
57001^A Triggering evidence: Documentation of encephalopathy (+/-) Clinical evidence of encephalopathy: • Altered mental status • Asterixis • Hallucinations • Hypercapnia • Seizure • Lethargy (+/-) Lab evidence of encephalopathy: • Magnesium <= 1 • Calcium <=6 or >=13 • Sodium <=130 or >145 • Thiamine <2.5 • Phosphorus <2 • Ammonia >100 umol/L • Glucose <50 mg/dL • GFR <15 mL/min • pCO2 arterial >45 mmHg • pCO2 venous >45 mmHg • pO2 arterial <60 mmHg • Vitamin B12 <200 pg/mL • O2 sat <90% Satisfying evidence: Documentation of the etiology OR type of encephalopathy: • Including but not limited to: • Hypertensive encephalopathy • Infectious encephalopathy • Metabolic encephalopathy • Toxic encephalopathy • Hepatic encephalopathy • Any provider linked cause of encephalopathy • Idopathic encephalopathy • Multifactorial encephalopathy	✔	✔	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 Triggering evidence: Documentation of encephalopathy AND Clinical evidence of coma : • Absent corneal reflexes • Decerebrate posture • Decorticate posture • Fixed dilation of pupil • No pupillary reaction to light • Persistent vegetative state • Unconscious/ Unresponsive OR GCS > 9 Satisfying evidence: Documentation of coma	✔	✔	Documentation of encephalopathy and clinical evidence of coma without documentation of coma	ENCEPHALOPATHY There is documentation of encephalopathy and clinical evidence of decreased responsiveness. Please document any associated diagnosis.	✔	✔	✔	✔
57004 Triggering evidence: Documentation of altered mental status OR confusion: • Acute confusion • Clouded consciousness • Confused • AMS Satisfying evidence: Documentation of the presence OR absence of encephalopathy: • Traumatic encephalopathy • Hashimoto’s encephalopathy • Ischemic encephalopathy • Hypertensive encephalopathy • Infectious encephalopathy • Metabolic encephalopathy • Wernicke Encephalopathy • Hepatic encephalopathy	✔	✔	Documentation of altered mental status or confusion without documentation of the presence or absence of encephalopathy	ALTERED MENTAL STATUS - D Altered mental status or confusion have been documented. Please document any associated diagnosis.	✔	✔	✔	✔
57005 Triggering evidence: Documentation of AMS AND MIN,2 Clinical evidence of encephalopathy OR metabolic encephalopathy: • Including but not limited to: • Ataxia • Hyponatremia • Agitation • Decreased level of consciousness • AKI • Respiratory failure • Electrolyte imbalance OR Lab evidence of encephalopathy: • Magnesium <= 1 • Calcium <=6 or >=13 • Sodium <=130 or >145 • Thiamine <2.5 • Phosphorus <2 • Ammonia >100 umol/L • Glucose <50 mg/dL • GFR <15 mL/min • pCO2 arterial >45 mmHg • pCO2 venous >45 mmHg • pO2 arterial <60 mmHg • Vitamin B12 <200 pg/mL • O2 sat <90% OR Chemical evidence of encephalopathy: • Including but not limited to: • Antihymocyte immunoglobulin • Organic chemical solvents • Formalin • Formaldehyde • Tetrachloroethylene Satisfying evidence: Documentation of metabolic encephalopathy: • Metabolic encephalopathy • Toxic encephalopathy • Sepsis-associated encephalopathy • Hypertensice encephalopathy • Hepatic encephalopathy • Alcoholic encephalopathy	✔	✔	Documentation of altered mental status and clinical 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 document any associated diagnosis.		✔
Encephalopathy-001 Triggering evidence: Documentation of encephalopathy Satisfying evidence: Documentation of the type OR etiology of encephalopathy: • Including but not limited to: • Hypertensive encephalopathy • Infectious encephalopathy • Metabolic encephalopathy • Toxic encephalopathy • Hepatic encephalopathy • Any provider linked cause of encephalopathy • Idopathic encephalopathy • Multifactorial encephalopathy AND Clinical evidence of encephalopathy: • Altered mental status • Asterixis • Hallucinations • Hypercapnia • Seizure • Lethargy OR Lab evidence of encephalopathy: • Magnesium <= 1 • Calcium <=6 or >=13 • Sodium <=130 or >145 • Thiamine <2.5 • Phosphorus <2 • Ammonia >100 umol/L • Glucose <50 mg/dL • GFR <15 mL/min • pCO2 arterial >45 mmHg • pCO2 venous >45 mmHg • pO2 arterial <60 mmHg • Vitamin B12 <200 pg/mL • O2 sat <90%	✔	✔	Documentation of encephalopathy without clinical or lab evidence of encephalopathy and documentation of type or etiology of encephalopathy	ENCEPHALOPATHY TYPE AND EVIDENCE Please specify the type or etiology of encephalpathy and include clinical indicators supporting the diagnosis.	✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
150008 Triggering evidence: Documentation of hydrocephalus: • Communicating hydrocephalus • Hydrocephalus • Normal pressure hydrocephalus • Obstructive hydrocephalus Satisfying evidence: Documentation of the type of hydrocephalus: • Communicating hydrocephalus • Normal pressure hydrocephalus • Obstructive hydrocephalus	✔	✔	Documentation of hydrocephalus without documentation of the type of hydrocephalus	HYDROCEPHALUS Please specify the type of hydrocephalus, if known.	✔			✔
150009 Triggering evidence: Documentation of VP (ventricular peritoneal) shunt: • Including but not limited to: • Ventriculoperitoneal shunt • Ventriculoperitoneal shunt malfunction • Ventriculoperitoneal shunt infection Satisfying evidence: Documentation of hydrocephalus: • Communicating hydrocephalus • Hydrocephalus • Normal pressure hydrocephalus • Obstructive hydrocephalus	✔	✔	Documentation of ventriculoperitoneal shunt without documentation of hydrocephalus	VP SHUNT There is documentation of VP (ventricular peritoneal) shunt. Please document the underlying condition.	✔			✔
150017* Triggering evidence: Documentation of VP (ventriculoperitoneal) shunt: • Ventriculoperitoneal shunt • Ventriculoperitoneal shunt peritonitis • Ventriculoperitoneal shunt malfunction • Ventriculoperitoneal shunt infection		✔	Notification: Documentation of ventriculoperitoneal shunt

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
Metastatic-001 Triggering evidence: Documentation of a brain tumor AND No documentation of glioma AND No documentation of primary malignant neoplasm of brain AND No documentation of benign brain tumor Satisfying evidence: Documentation of the presence or absence of brain metastasis	✔	✔	Documentation of brain tumor without documentation of the presence or absence of metastatic brain disease	BRAIN TUMOR There is documentation of a brain tumor. Please document the status of metastatic brain disease, if known.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12011 Triggering evidence: Documentation of abnormal gait: • Abnormal gait • Ataxic gait • Unsteady gait Satisfying evidence: Documentation of the type of abnormal gait: • Limping gait • Staggering gait • Spastic gait • Stumbling gait • Paraplegic gait	✔	✔	Documentation of abnormal gait without documentation of the type of abnormal gait	ABNORMAL GAIT Please document the type of gait abnormality.				✔
150006 Triggering evidence: Documentation of ataxia Satisfying evidence: Documentation of the type of ataxia: • Including but not limited to: • Cerebellar ataxia • Friedreich's ataxia • Idiopathic ataxia • Episodic ataxia • Ataxia-telangiectasia syndrome OR Documentation of the etiology of ataxia: • Head injury • Stroke • Cerebral palsy • Encephalitis/meningitis • Multiple sclerosis • Any provider linked cause of ataxia	✔	✔	Documentation of ataxia without documentation of the type or etiology of ataxia	ATAXIA Please document the type or etiology of ataxia.	✔		✔	✔
150010 Triggering evidence: Documentation of aphasia: • Anomic aphasia • Broca's dysphasia • Expressive aphasia • Global aphasia • Mixed dysphasia • Receptive dysphasia Satisfying evidence: Documentation of the type of aphasia: • Anomic aphasia • Expressive aphasia • Global aphasia • Mixed dysphasia • Receptive dysphasia	✔	✔	Documentation of aphasia without documentation of the type of aphasia	APHASIA Please document the type of aphasia.				✔
150012 Triggering evidence: MIN 2, Documentation of seizure: • Seizure disorder • Partial seizure • Epilepsy • Simple seizure • Partial seizure • Focal seizure • Satisfying evidence: Documentation of the type of seizure: • Absence seizure • Atypical seizure • Clonic seizure • Myoclonic seizure • Tonic seizure • Atonic seizure • OR documentation of unknown type of seizure	✔	✔	Documentation of seizure without documentation of type of seizure	SEIZURE Please document the type of seizure.	✔	✔		✔
150016* Triggering evidence: Documentation of weakness, hemiparesis, hemiplegia, monoparesis, OR monoplegia		✔	Notification: Documentation of weakness, hemiparesis, or hemiplegia, or monoparesis, or monoplegia
150021 Triggering evidence: Documentation of dysarthria OR anarthria: • Flaccid dysarthria • Spastic dysarthria • Ataxic dysarthria • Hypokinetic dysarthria • Hyperkinetic dysarthria • Mixed type dysarthria Satisfying evidence: Documentation of the etiology of dysarthria OR anarthria: • Traumatic/non-traumatic brain injury • Cerebral palsy • Multiple sclerosis • Parkinson's disease • Huntington's disease • Mass lesion of the brain	✔	✔	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 Triggering evidence: Documentation of EMG OR nerve conduction study Satisfying evidence: Documentation of limb AND laterality : • Including but not limited to: • Entire limb • Upper limb • Lower limb • Entire forearm	✔	✔	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 Triggering evidence: Documentation of weakness: • Asthenia • Muscle weakness Satisfying evidence: Documentation of the laterality of weakness: • Unilateral • Unspecified laterality	✔	✔	Documentation of weakness without documentation of the laterality of weakness	WEAKNESS Please document the laterality of weakness.			✔	✔
43006 Triggering evidence: MIN,2 Documentation of diabetes : • Including but not limited to: • Diabetes mellitus • Gestational diabetes • Brittle diabetes • Diabetic foot ulcer AND documentation of a neuropathic agents: • Anticonvulsants Satisfying evidence: Documentation of diabetic peripheral neuropathy	✔	✔	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 Triggering evidence: MIN,2 Documentation of seizure : • Generalized seizure • Partial seizure • Familial neonatal seizure • Status epilepticus • Familial febrile convulsions (+/-) Evidence of seizure: • Including but not limited to: • Temperature >104.4 F or 40.22 C • Traumatic brain injury • Acohol or Drug abuse or withdrawal • TIA or CVA • Family history of seizures Satisfying evidence: Documentation of the type of seizure : • Including but not limited to: • Tonic seizure • Atonic seizure • Myoclonic seizure • Clonic seizure • Grand mal OR documentation of unknown type of seizure	✔	✔	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.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
41001 Triggering evidence: Documentation of spina bifida: • Spina bifida • Meningocele • Myelomeningocele • Closed neural tube defect Satisfying evidence: Documentation of the affected spinal segment: • Including but not limited to: • Cerebral meningocele • Spina bifida of lumbar region • Spina bifida of thoracic region • Spina bifida of sacral region • Spina bifida of cervical region	✔	✔	Documentation of spina bifida without documentation of the affected spinal segment	SPINA BIFIDA Please document the spinal level of spina bifida.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
150025 Triggering evidence: MIN,2 documentation of transient ischemic attack : • Transient ischemic attack • Carotid territory transient ischemic attack • Recurrent transient ischemic attack (+/-) documentation of a history of stroke (+/-) clinical evidence of the etiology of transient ischemic attack : • Atrial fibrillation • Arteriosclerosis • Hypercholesterolemia • Hypertension Satisfying evidence: Documentation of the etiology of transient ischemic attack: • Including but not limited to: • Hypertension • Arrythmia • Arteriosclerosis • Hypercholesterolemia • Any physician documented cause of transient ischemic attack	✔	✔	Documentation of transient ischemic attack (+/- history of stroke or clinical 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.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
44001 Triggering evidence: Documentation of cleft palate Satisfying evidence: Documentation of site as hard palate, soft palate, OR hard and soft palate	✔	✔	Documentation of cleft palate without documentation of site	Cleft palate was documented. Please document the site of cleft palate.
44002 Triggering evidence: Documentation of cleft lip : • Cleft lip • Cleft lip and aveolus • Cleft lip nasal deformity Satisfying evidence: Documentation of site as bilateral, median, OR unilateral: • Bilateral cleft lip • Central cleft lip	✔	✔	Documentation of cleft lip without documentation of laterality	Cleft lip was documented. Please document the site of cleft lip, if known.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
60301 Triggering evidence: Documentation of head OR neck cancer Satisfying evidence: Documentation of the site of the head OR neck cancer: • Including but not limited to: • Ear, nose and throat • Skull • Cervical vertebra • Face	✔	✔	Documentation of head or neck cancer without documentation of the specific site of the cancer	HEAD/NECK CANCER There is documentation of head or neck cancer. Please document the site of the cancer.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
50205 Triggering evidence: Documentation of mastoiditis (+/-) evidence of mastoiditis: • Bleeding from ear • Headache • Tender mastoid • Otalgia • Fever Satisfying evidence: Documentation of acuity of mastoiditis: • Empyema of mastoid • Caries of mastoid • Acute mastoiditis • Chronic mastoiditis • Acute on chronic mastoiditis	✔	✔	Documentation of mastoiditis (+/- clinical evidence of mastoiditis) without documentation of the acuity of mastoiditis	MASTOIDITIS Please document the acuity of mastoiditis.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
40101^P Triggering evidence: Documentation of acute bronchiolitis: • Including but not limited to: • Bronchiolitis • Acute bronchiolitis • Diffuse panbronchiolitis • Obliterative bronchiolitis • Subacute obliterative bronchiolitis Satisfying evidence: Documentation of organism: • Human metapneumovirus • Influenza • Microorganism • Respiratory syncytial virus	✔	✔	Pediatric: Documentation of bronchiolitis without documentation of the causative organism of bronchiolitis	BRONCHIOLITIS Please document the causative organism for acute bronchiolitis, if known.	✔
40102 Triggering evidence: Documentation of RSV: • Human respiratory syncytial virus • Respiratory syncytial virus bronchiolitis • Respiratory syncytial virus pneumonia Satisfying evidence: Documentation of RSV bronchiolitis OR RSV pneumonia: • Respiratory syncytial virus bronchiolitis • Acute bronchiolitis caused by respiratory syncytial virus • Respiratory syncytial virus pneumonia • Respiratory syncytial virus bronchopneumonia	✔	✔	Documentation of RSV without documentation of RSV bronchiolitis or pneumonia	RSV There is documentation of RSV. Please document any associated diagnosis.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12008 Triggering evidence: Documentation of pleural effusion : • Pleural effusion • Chylothorax • Hydrothorax (+/-) evidence of pleural effusion: • Cough • Fever • Pleurisy • Pleuritic pain • Shortness of breath Satisfying evidence: Documentation of pleural effusion type: • Hemothorax (or subtype) • Pleural effusion (or subtype)	✔	✔	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 Triggering evidence: Documentation of pulmonary edema (+/-) clinical evidence of pulmonary edema: • Dyspnea • Gasping for breath • Bloodstained sputum • Palpitations • Restlessness and agitation AND NO documentation of congestive heart failure OR heart failure OR myocardial infarction Satisfying evidence: Documentation of the acuity of pulmonary edema: • Acute • Chronic • Acute-on-chronic		✔	Documentation of pulmonary edema (+/- clinical evidence of pulmonary edema) without documentation of the acuity of pulmonary edema			✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
32000 Triggering evidence: MIN,2 Documentation of asthma (+/-) Respiratory evidence of asthma exacerbation: • Respiratory rate >= 24 (+/-) Clinical evidence of asthma exacerbation: • Including but not limited to: • Clouded consciousness • Dependence on ventilator • Acute respiratory distress • Respiratory crackles • Wheezing (+/-) Medication evidence of asthma exacerbation: • Including but not limited to: • Azithromycin • Inhalation Bronchodilator • Corticosteroid • Levalbuterol • Ipratropium Satisfying evidence: Documentation of severity : • Intermittent • Persistent-mild • Persistent-moderate • Persistent-severe AND documentation of acuity of asthma: • Acute • Chronic • Acute on chronic	✔	✔	Documentation of asthma (+/- clinical evidence of asthma exacerbation or documentation of asthma medication) without documentation of the severity and acuity of asthma	ASTHMA Please document the severity and acuity of asthma.	✔			✔
32001 Triggering evidence: MIN,2 Documentation of asthma (+/-) Respiratory evidence of asthma exacerbation: • Respiratory rate >= 24 (+/-) Clinical evidence of asthma exacerbation: • Including but not limited to: • Clouded consciousness • Dependence on ventilator • Acute respiratory distress • Respiratory crackles • Wheezing (+/-) Medication evidence of asthma exacerbation: • Including but not limited to: • Azithromycin • Inhalation Bronchodilator • Corticosteroid • Levalbuterol • Ipratropium Satisfying evidence: Documentation of type of asthma: • Including but not limited to: • Allergic asthma • Persistent asthma • Substance induced asthma • Chronic obstructive asthma • Seasonal asthma	✔	✔	Documentation of asthma (+/- clinical or medication evidence of asthma) without documentation of type of asthma	ASTHMA - TYPE Please document the type of asthma.	✔			✔
46003 Triggering evidence: Documentation of asthma AND Medication evidence of acute exacerbation: • Including but not limited to: • ShortActingBetaAgonists • Atrovent • Corticosteroid • Oxygen • Symbicort OR Clinical evidence of acute exacerbation: • Including but not limited to: • Excessive sweating • Chest wall retraction • Tachycardia • Tachypnea • Wheezing Satisfying evidence: Documentation of acute exacerbation OR status asthmaticus	✔	✔	Documentation of asthma and clinical or medication evidence of asthma exacerbation without documentation of acute exacerbation or status asthmaticus	ASTHMA - D There is documentation and clinical or medication evidence of asthma. Please document any associated diagnosis.	✔			✔
46004 Triggering evidence: Documentation of asthma Satisfying evidence: Documentation of the severity of asthma: • Intermittent • Persistent-mild • Persistent-moderate • Persistent-severe	✔	✔	Documentation of asthma without documentation of severity of asthma	ASTHMA - SEVERITY Please document the severity of asthma.	✔			✔
46005 Triggering evidence: Documentation of mild asthma: • Mild • Mild to moderate Satisfying evidence: Documentation of persistence: • Intermittent • Persistent	✔	✔	Documentation of mild asthma without documentation of persistence of asthma	ASTHMA - PERSISTENCE There is documentation of mild asthma. Please specify persistence.	✔			✔
46006 Triggering evidence: Documentation of asthma Satisfying evidence: Documentation of severity of persistent asthma: • Mild • Moderate • Severe OR Documentation of intermittent asthma AND Documentation of presense or absence of acute exacerbation OR status asthmaticus OR uncomplicated asthma	✔	✔	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 - STATUS Please document the severity, persistence, and status of asthma.	✔			✔
PedAsthma-001^P Triggering evidence: Documentation of asthma exacerbation : • Including but not limited to: • Short Acting Beta Agonists • Atrovent • Corticosteroid • Oxygen • Symbicort (+/-) Procedure evidence of asthma exacerbation: • Incentive spirometry • Peak expiratory flow rate • Spirometry (+/-) Medication evidence of asthma exacerbation: • Including, but not limited to: • ShortActingBetaAgonists • Atrovent • Corticosteroid • Oxygen • Symbicort Satisfying evidence: Documentation of acute status asthmaticus	✔	✔	Pediatric: Documentation of asthma exacerbation (+/- medication or procedure evidence of asthma exacerbation) without documentation of acuity of status asthmaticus	PEDIATRIC ASTHMA Please document acuity of status asthmaticus.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
11010 Triggering evidence: Documentation of continuous home oxygen use AND documentation of COPD : • Chronic obstructive pulmonary disease including but not limited to: • Chronic obstructive pulmonary disease • Acute exacerbation of chronic obstructive pulmonary disease • Chronic obliterative bronchiolitis • Pulmonary emphysema • End stage chronic obstructive pulmonary disease • Mild/moderate/severe chronic obstructive pulmonary disease (+/-) lab evidence of chronic respiratory failure : • Bicarbonate (HCO3) • Arterial pH • Arterial pCO2 Satisfying evidence: Documentation of chronic respiratory failure: • Chronic respiratory failure including but not limited to: • Chronic respiratory failure • Acute-on-chronic hypoxemic respiratory failure • Chronic hypercapnic respiratory failure • Chronic hypoxemic respiratory failure • Acute-on-chronic respiratory failure	✔	✔	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 Triggering evidence: Documentation of COPD: • Chronic obstructive pulmonary disease including but not limited to: • Acute exacerbation of chronic obstructive pulmonary disease • Chronic obliterative bronchiolitis • Pulmonary emphysema • End stage chronic obstructive pulmonary disease • Mild/moderate/severe chronic obstructive pulmonary disease AND documentation of home oxygen use : • Long-term oxygen therapy • Home oxygen supply • Home oxygen therapy • Night-time oxygen therapy • Continuous home oxygen therapy (+/-) lab evidence of chronic respiratory failure: • Bicarbonate (HCO3) • Arterial pH • Arterial pCO2 Satisfying evidence: Documentation of chronic respiratory failure: • Chronic respiratory failure including but not limited to: • Chronic respiratory failure • Acute-on-chronic hypoxemic respiratory failure • Chronic hypercapnic respiratory failure • Chronic hypoxemic respiratory failure • Acute-on-chronic respiratory failure	✔	✔	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* Triggering evidence: Documentation of COPD : • Chronic obstructive pulmonary disease including but not limited to: • Acute exacerbation of chronic obstructive pulmonary disease • Chronic obliterative bronchiolitis • Pulmonary emphysema • End stage chronic obstructive pulmonary disease • Mild/moderate/severe chronic obstructive pulmonary disease AND NO documentation of asthma AND NO documentation of bronchitis AND MIN 2, clinical evidence of COPD exacerbation: • Clouded consciousness • Dependence on ventilator • Acute respiratory distress • Respiratory crackles • Wheezing • Respiratory rate >= 24 breaths/min OR medication evidence of COPD exacerbation: • Azithromycin • Inhalation bronchodilator • Corticosteroid • Levalbuterol • Ipratropium		✔	Notification: Documentation of COPD and clinical or medication evidence of COPD exacerbation
11019 Triggering evidence: Documentation of acute exacerbation of COPD (+/-) respiratory rate >= 24 breaths/min (+/-) clinical evidence of COPD exacerbation: • Clouded consciousness • Dependence on ventilator • Acute respiratory distress • Respiratory crackles • Wheezing (+/-) medication evidence of COPD exacerbation: • Including but not limited to: • Azithromycin • Inhalation bronchodilator • Corticosteroid • Levalbuterol • Ipratropium Satisfying evidence: Documentation of the etiology of acute exacerbation of COPD : • Including but not limited to: • Any physician etiology linked to acute exacerbation of COPD • Pollen • Dust • Fume • Animal dander	✔	✔	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, if known.
11021 Triggering evidence: Documentation of home oxygen AND documentation of chronic respiratory failure OR documentation of COPD OR pulmonary fibrosis: • Chronic obstructive pulmonary disease including but not limited to: • Acute exacerbation of chronic obstructive pulmonary disease • Chronic obliterative bronchiolitis • Pulmonary emphysema • End stage chronic obstructive pulmonary disease • Mild/moderate/severe chronic obstructive pulmonary disease (+/-) lab evidence of chronic respiratory failure: • Bicarbonate (HCO3) • Arterial pH • Arterial pCO2 (+/-) clinical evidence of chronic respiratory failure: • Hypoxemia • Hypoxia • Supplemental oxygen • Home oxygen Satisfying evidence: Documentation of the volume of home oxygen (liter flow)	✔	✔	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	HOME OXYGEN - D There is documentation of home oxygen and chronic lung condition, please document home oxygen volume.				✔
12009 Triggering evidence: Documentation of acute bronchitis : • Acute bronchitis • Acute bronchiolitis • Pertussis (+/-) evidence of acute bronchitis: • Cough • Productive cough • Fatigue • Shortness of breath • Wheezing Satisfying evidence: Documentation of the underlying cause of acute bronchitis: • Including but not limited to: • Any physician etiology linked to acute infective bronchitis • Idiopathic acute infective bronchitis • Multifactorial acute infective bronchitis	✔	✔	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, if known.
50206 Triggering evidence: MIN,2 Documentation of bronchitis (+/-) evidence of bronchitis: • Including, but not limited to: • Cough • Fatigue • Shortness of breath • Wheezing Satisfying evidence: Documentation of acuity of bronchitis: • Acute • Chronic • Acute on chronic	✔	✔	Documentation of bronchitis (+/- clinical evidence of acute bronchitis) without documentation of the acuity of bronchitis	BRONCHITIS Please document the acuity of bronchitis.			✔	✔
59001 Triggering evidence: Documentation of COPD : • Asthma-chronic obstructive pulmonary disease overlap syndrome • Chronic obstructive pulmonary disease • Congenital lobar emphysema AND NO documentation of emphysema AND clinical evidence of COPD exacerbation : • Dependence on ventilator • Decreased breath sounds • Respiratory crackles • Wheezing • Respiratory rate >= 24 breaths/min (+/-) evidence of exacerbation related medication: • Azithromycin • Inhalation Bronchodilator • Corticosteroid • Levalbuterol • Ipratropium Satisfying evidence: Documentation of status of COPD: • Exacerbation • Stable • Without exacerbation	✔	✔	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 other respiratory signs and symptoms. Please document the COPD status.	✔
COPD-001 Triggering evidence: Documentation of COPD : • Asthma-chronic obstructive pulmonary disease overlap syndrome • Chronic obstructive pulmonary disease • Congenital lobar emphysema Satisfying evidence: Documentation of COPD status: • Exacerbation • Stable • Without exacerbation	✔	✔	Documentation of COPD without documentation of COPD status	COPD - C Please document the status of COPD.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
17001 Triggering evidence: Documentation of transbronchial biopsy Satisfying evidence: Documentation of lung tissue OR lung OR lymph node (+/-) Evidence of lung : • Including but not limited to: • Atelectasis • Bronchiole structure • Infiltration • Pneumocyte • Pneumonia • Sarcoidosis (+/-) Evidence of lung part: • Entire bronchiole • Entire pulmonary alveolus • Pneumocyte	✔	✔	Documentation of transbronchial biopsy without documentation of lung or lung tissue	TRANSBRONCHIAL BIOPSY SITE Please document the site of the transbronchial biopsy.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
15018* Triggering evidence: Documentation of the presence of COVID-19 : • Including, but not limited to: • Coronavirus infection • Human coronavirus • Severe acute respiratory syndrome coronavirus • Severe acute respiratory syndrome coronavirus 2 OR documentation of coronavirus (COVID-19) positive lab results (+/-) evidence of COVID-19 symptoms : • Including, but not limited to: • Cough • Diarrhea • Dyspnea • Fatigue • Fever • Loss of sense of smell • Loss of taste (+/-) evidence of COVID-19 comorbidities : • Including, but not limited to: • Asthma • Cancer • Chronic kidney disease • Cirrhosis • Diabetes mellitus • Heart failure (+/-) evidence of COVID-19 risk factors : • Including, but not limited to: • Food insecurity • Lives alone • Chemo/Radiation therapy • Smoker/Vaping • Transplantation of bone marrow (+/-) documentation of ventilator/intubation/tracheostomy : • Including, but not limited to: • Artificial respiration • Continous mandatory ventilation • Controlled ventilation • Endotracheal tube • Intubation • Mechanical Ventilator • Tracheostomy (+/-) documentation of respiratory procedures/treatments : • Including, but not limited to: • Oxygen amount • Oxygen therapy • Ventilation criteria (CPAP treatment, tube feeding, chest drain, etc.) • Ventilation criteria procedures (Weaning, suctioning, nebulizer therapy, etc.) (+/-) documentation of FiO2 or oxygen concentration		✔	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* Triggering evidence: Documentation of possible COVID-19 : • Including but not limited to: • Coronavirus infection • Human coronavirus • Pneumonia caused by Human coronavirus • Severe acute respiratory syndrome coronavirus • Severe acute respiratory syndrome coronavirus 2 (+/-) documentation of respiratory procedures/treatments : • Including but not limited to: • Oxygen amount • Oxygen therapy • Ventilation criteria (CPAP treatment, tube feeding, chest drain, etc.) • Ventilation criteria procedures (Weaning, suctioning, nebulizer therapy, etc.) (+/-) documentation of ventilator/intubation/tracheostomy : • Including but not limited to: • Artificial respiration • Continous mandatory ventilation • Controlled ventilation • Intubation • Mechanical Ventilator • Tracheostomy (+/-) documentation of FiO2 or oxygen concentration (+/-) evidence of COVID-19 comorbidities: • Including but not limited to: • Asthma • Cancer • Chronic kidney disease • Cirrhosis • Diabetes mellitus • Heart failure (+/-) evidence of COVID-19 risk factors: • Including, but not limited to: • Food insecurity • Lives alone or homeless • Radiation/ chemo therapy • Smoking or vaping • Transplantation of bone marrow (+/-) evidence of COVID-19 symptoms : • Including, but not limited to: • Cough • Diarrhea • Dyspnea • Fatigue • Fever (>100.4 F or 38 C) • Loss of sense of smell • Loss of taste • Ground-glass/ opacity on X-ray AND NO Documentation of negative coronavirus (COVID-19) OR negative coronavirus (COVID-19) lab result		✔	Notification: Documentation of possible COVID-19 (+/- documentation of oxygen therapy, ventilator therapy, COVID-19 symptoms, COVID-19 comorbidities, or COVID-19 risk factors)
51000549 Triggering evidence: Documentation of COVID-19 Satisfying evidence: Documentation of status of COVID-19: • History of • Active status • Sequela	✔	✔	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.		✔		✔
51001103* Triggering evidence: Documentation of COVID-19 vaccine received: • COVID-19 vaccinated • COVID-19 booster vaccination Documentation of administration of COVID-19 vaccine: • mRNA vaccine • Vector vaccine • Protein subunit vaccine • Inactivated virus vaccine • Live attenuated virus vaccine • Unknown/unspecified vaccine product		✔	Notification: Documentation of COVID-19 vaccine received
COVID-001 Triggering evidence: Documentation of coronavirus (COVID-19) OR positive COVID-19 lab results AND documentation of a complication: • Including but not limited to: • Acute kidney injury • Acute respiratory distress syndrome • Acute respiratory failure • Pneumonia • Sepsis Satisfying evidence: Documentation of whether there is a link between COVID-19 AND the complication: • Any provider documented presence or absence of relationship	✔	✔	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 are documented. Please clarify whether these are causally related.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51000442 Triggering evidence: Documentation of malignant effusion Satisfying evidence: Documentation of primary malignancy site : • Any provider linked site of primary malignancy	✔	✔	Documentation of malignant effusion without documentation of the primary malignancy site	MALIGNANT EFFUSION Please document the primary malignancy site associated with the malignant effusion.
67001 Triggering evidence: Presence of lung cancer: • Including but not limited to: • Malignant epithelial neoplasm • Primary malignant neoplasm • Malignant neoplasm of lower lobe • Malignant neoplasm of upper lobe • Malignant tumor of bronchus Satisfying evidence: Documentation of site of the affected lung: • Any provider linked specific site of: • Bronchus • Lobar bronchus • Lung structure AND Documentation of the laterality of affected lung : • Right • Left • Bilateral	✔	✔	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.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
11022 Triggering evidence: Documentation of home oxygen use: • Amount of home oxygen • Long-term oxygen therapy • Home oxygen supply • Home oxygen therapy • Night-time oxygen therapy • Continuous home oxygen therapy Satisfying evidence: Documentation of home oxygen use associated disorder: • Including but not limited to: • Asthma • Chronic obstructive pulmonary disease (COPD) • Heart failure • Chronic respiratory failure • Pulmonary hypertension • Malignant tumor of lung		✔	Documentation of home oxygen use without documentation of associated respiratory disorder
51001782 Triggering evidence: Documentation of pulmonary edema (+/-) clinical evidence of pulmonary edema: • Dyspnea • Gasping for breath • Bloodstained sputum • Palpitations • Restlessness and agitation AND NO documentation of heart failure OR myocardial infarction Satisfying evidence: Documentation of the acuity of pulmonary edema	✔	✔	Provider documentation of pulmonary edema (+/- clinical evidence of pulmonary edema) without documentation of the acuity of pulmonary edema	PULMONARY EDEMA Please document the acuity of pulmonary edema.		✔	✔	✔
OtherResp-001* Triggering evidence: Documentation of CPAP or BIPAP		✔	Notification: There is documentation of CPAP or BIPAP

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
15002* Triggering evidence: MIN 2, documentation of pneumonia (+/-) evidence of pneumonia: • Including but not limited to: • Cough • Chest pain • Fever • Consolidation on x-ray • Radiologic infiltrate • Abnormal breath sounds • Difficulty breathing (+/-) documentation of causative organism		✔	Notification: Documentation of pneumonia (+/- documentation of causative organism of pneumonia or clinical or radiologic evidence of pneumonia)		✔	✔	✔	✔
15003 Triggering evidence: MIN 2, Documentation of pneumonia AND documentation of ventilator: • Mechanical ventilator • Intubation • Positive end expiratory pressure • Pressure controlled ventilation • Volume controlled ventilation • Intermittent positive pressure ventilation • Continuous mandatory ventilation • Continuous positive airway pressure (+/-) clinical evidence of gram negative infection: • Bronchiectasis • Chronic obstructive pulmonary disease • Cystic fibrosis • Immunosuppression • Lives in a nursing home (+/-) medication evidence of gram negative infection: • Ceftazidime • Ciprofloxacin • Levofloxacin • Piperacillin • Tobramycin AND NO documentation of aspiration pneumonia Satisfying evidence: Documentation of ventilator pneumonia	✔	✔	Documentation of pneumonia and clinical evidence of ventilator (+/- clinical or medication evidence of Gram negative pneumonia) without documentation of ventilator-acquired pneumonia	PNEUMONIA - D There is documentation of pneumonia and use of mechanical ventilation. Please document any associated diagnosis.	✔		✔	✔
15005 Triggering evidence: MIN2, Documentation of pneumonia AND MIN2, clinical evidence of aspiration pneumonia: • Alcohol abuse • Bed-ridden • Cerebrovascular accident • Pulmonary aspiration • Swallowing problem OR medication evidence of aspiration pneumonia: • Ampicillin / Sulbactam • Cefotaxime • Ceftriaxone • Clindamycin • Imipenem • Piperacillin • Meropenem OR radiologic evidence of aspiration pneumonia: • Lower zone (basal) pneumonia Satisfying evidence: Documentation of aspiration pneumonia	✔	✔	Documentation of pneumonia and clinical, medication, or radiologic evidence of aspiration without documentation of aspiration pneumonia	PNEUMONIA - C There is documentation of pneumonia and clinical, medication, or radiologic evidence of a specific type. Please further specify pneumonia, if known.		✔	✔	✔
15006 Triggering evidence: MIN 2, Documentation of pneumonia (+/-) evidence of positive pneumonia assessment findings: • Cough • Chest pain • Fever • Consolidation on x-ray • Radiologic infiltrate • Abnormal breath sounds • Difficulty breathing (+/-) evidence of aspiration pneumonia: • Ampicillin / Sulbactam • Cefotaxime • Ceftriaxone • Clindamycin • Imipenem • Piperacillin • Meropenem • Lower zone pneumonia on x-ray • Alcohol abuse • Bed-ridden • Cerebrovascular accident • Pulmonary aspiration • Swallowing problem (+/-) evidence of Staph/MRSA pneumonia: • Vancomycin • Zyvox • Linezolid • Artificial respiration • Immunosuppression • Open wound • Pressure ulcer (+/-) evidence of ventilator pneumonia: • Including but not limited to: • Mechanical ventilator • Positive end expiratory pressure • Pressure controlled ventilation • Volume controlled ventilation • Intermittent positive pressure ventilation • Continuous mandatory ventilation • Continuous positive airway pressure (+/-) evidence of gram negative pneumonia: • Ceftazidime • Ciprofloxacin • Piperacillin • Tazobactam • Tobramycin • Bronchiectasis • Immunosuppression • Chronic obstructive pulmonary disease • Cystic fibrosis • End-stage renal disease Satisfying evidence: Documentation of the type OR causative organism of pneumonia: • Including but not limited to: • Aspiration pneumonia • Influenza A pneumonia • Ventilator associated pneumonia • Pneumonia due to staph aureus •	✔	✔	Documentation of pneumonia (+/- evidence of aspiration, Gram negative, MRSA, or ventilator pneumonia) without documentation of the type or causative organism of pneumonia	PNEUMONIA Please document the type or causative organism of pneumonia.	✔	✔	✔	✔
15008* Triggering evidence: Documentation of possible pneumonia (+/-) clinical OR radiologic evidence of pneumonia: • Cough • Chest pain • Fever • Consolidation on x-ray • Radiologic infiltrate • Abnormal breath sounds • Difficulty breathing (+/-) documentation of causative organism: • Any provider linked organism as cause of pneumonia AND NO documentation of absence of OR ruled out pneumonia		✔	Notification: Documentation of possible pneumonia (+/- documentation of causative organism of pneumonia or clinical or radiologic evidence of pneumonia)
15009* Triggering evidence: Documentation of pneumonia present on admission: • Community acquired pneumonia • Any physician specified pneumonia present on admission		✔	Notification: Documentation that pneumonia was present on admission
15012 Triggering evidence: MIN 2, Documentation of pneumonia OR pneumonitis AND documentation of teleradiotherapy: • Including but not limited to: • Teleradiotherapy • Cobalt-60 therapy • Radiation therapy • Radionuclide therapy AND documentation of cough OR shortness of breath OR chest fullness: • Including but not limited to: • Chest fullness • Cough • Dyspnea • Painful cough • Shortness of breath AND NO documentation of fluoroscopy Satisfying evidence: Documentation of radiation-induced pneumonia OR pneumonitis: • Acute radiation pneumonitis • Post-radiotherapy pneumonitis • Radiation pneumonia • Radiation pneumonitis	✔	✔	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 the type of pneumonia.	✔		✔	✔
15013 Triggering evidence: Documentation of pneumonia Satisfying evidence: Documentation of the presence of pneumonia on the history and physical document OR documentation of negated pneumonia on the history and physical document OR documentation of pneumonia present on admission status	✔	✔	Documentation of pneumonia without documentation of present on admission status	PNEUMONIA POA Please document whether pneumonia was present on admission.		✔
15014 Triggering evidence: Documentation of healthcare associated pneumonia (HCAP): • Nosocomial pneumonia AND documentation of antibiotics for gram negative pneumonia: • Including but not limited to: • Amikacin • Ceftazidime • Gentamicin • Meropenem • Imipenem • Aztreonam • Levofloxacin • Zosyn • Cefepime Satisfying evidence: Documentation of gram negative pneumonia	✔	✔	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.		✔	✔	✔
15015 Triggering evidence: Documentation of healthcare-acquired pneumonia (HCAP): • Nosocomial pneumonia AND documentation of vancomycin Satisfying evidence: Documentation of pneumonia caused by methicillin resistant Staphylococcus aureus	✔	✔	Documentation of healthcare-acquired pneumonia and vancomycin without documentation of MRSA pneumonia	HCAP - VANCOMYCIN There is documentation of HCAP and vancomycin. Please document the causitive organism of pneumonia, if known.		✔	✔	✔
51000605 Triggering evidence: MIN,2 Documentation of pneumonia AND evidence of antibiotic therapy : • Including but not limited to: • Cefepime • Ceftazidime • Clindamycin • Imipenem • Levofloxacin • Meropenem • Piperacillin / tazobactam • Vancomycin Satisfying evidence: Documentation of type of pneumonia : • Aspiration pneumonia • Covid pneumonia • Gram negative pneumonia • Gram positive pneumonia • Viral pneumonia	✔	✔	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.	✔	✔	✔	✔
51001286 Triggering evidence: Documentation of pneumonia in the emergency department Satisfying evidence: Documentation of the presence or absence of pneumonia in the inpatient documentation	✔	✔	Documentation of pneumonia in the emergency department without documentation of pneumonia in the inpatient documentation	PNEUMONIA - A 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 Triggering evidence: MIN,2 Documentation of pneumonia (+/-) Documentation of causative organism Satisfying evidence: Clinical evidence of pneumonia: • Including but not limited to: • Abnormal breath sounds • Cough • Chest pain • Dyspnea • Fever • Radiologic infiltrate • Shortness of breath	✔	✔	Documentation of pneumonia (+/- causative organism of pneumonia) without clinical evidence of pneumonia	PNEUMONIA SUPPORTING EVIDENCE Please document the clinical indicators supporting the diagnosis of pneumonia.		✔
Pneumonia-007 Triggering evidence: Documentation of antibiotics administered : • Including but not limited to: • Clindamycin • Penicillin • Levofloxacin • Ciprofloxacin • Vancomycin AND radiological evidence of pneumonia : • Including but not limited to: • Homogeneous consolidation of lung • Lobar consolidation of lung • Lung consolidation • Radiologic infiltrate • Radiologic opacity (+/-) evidence of pneumonia: • Including but not limited to: • Cough • Chest pain • Abnormal breath sounds • Fever • Difficulty breathing Satisfying evidence: Documentation of causative organism : • Any provider linked organism as cause of pneumonia OR Documentation of type of pneumonia: • Including but not limited to: • Aspiration pneumonia • Bronchopneumonia • Community acquired pneumonia • Bacterial pneumonia • Viral pneumonia	✔	✔	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 disorder and evidence of antibiotic administration. Please document any associated diagnosis.	✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
11020* Triggering evidence: Documentation of post-operative respiratory failure (+/-) documentation of social history for smoking (+/-) Documentation of lung conditions: • Asthma • Chronic lung disease • Malignant tumor of lung • Pleural effusion • Pneumothorax		✔	Notification: Documentation of respiratory failure and post-operative period (+/- documentation of positive smoking history or respiratory diagnoses)

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
29006 Triggering evidence: Documentation of pulmonary embolism Satisfying evidence: Documentation of presence OR absence of cor pulmonale: • Acute cor pulmonale • Acute on chronic cor pulmonale • Chronic cor pulmonale • Cor pulmonale OR documentation of presence OR absence of right ventricular strain	✔	✔	Documentation of pulmonary embolism without documentation of the presence or absence of cor pulmonale or right ventricular strain	PULMONARY EMBOLISM There is documentation of pulmonary embolism. Please document the presense or absense of any associated complication or diagnosis.		✔
29007 Triggering evidence: Documentation of pulmonary embolism Satisfying evidence: Documentation of cause of pulmonary embolism: • Any provider linked cause to PE	✔	✔	Documentation of pulmonary embolism without documentation of the etiology of pulmonary embolism	PULMONARY EMBOLISM - CAUSE Please document the cause of pulmonary embolism.		✔
29013 Triggering evidence: Documentation of pulmonary embolism Satisfying evidence: Documentation of the presence of pulmonary embolism on the history and physical document OR Documentation of negated pulmonary embolism on the history and physical document OR Documentation of pulmonary embolism present on admission status	✔	✔	Documentation of pulmonary embolism without documentation of present on admission status	PULMONARY EMBOLISM POA Please document whether pulmonary embolism was present on admission.		✔
50202 Triggering evidence: Documentation of pulmonary embolism Satisfying evidence: Documentation of acuity of pulmonary embolism : • Acute • Chronic • Subacute • Acute on chronic	✔	✔	Documentation of pulmonary embolism without documentation of the acuity of pulmonary embolism	PULMONARY EMBOLISM - ACUITY Please document the acuity of the pulmonary embolism.	✔	✔
51002122 Triggering evidence: Documentation of pulmonary embolism Satisfying evidence: Documentation of the type of pulmonary embolism: • Saddle embolus of pulmonary artery • Segmental pulmonary embolism • Subsegmental pulmonary embolism	✔	✔	Documentation of pulmonary embolism without documentation of the type of pulmonary embolism	PULMONARY EMBOLISM - TYPE Please document the type of pulmonary embolism.		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
11000 Triggering evidence: Documentation of respiratory failure : • Respiratory failure including but not limited to: • Acute respiratory failure • Chronic respiratory failure • Hypoxemic respiratory failure • Hypercapnic respiratory failure • Neonatal respiratory failure • Postprocedural respiratory failure (+/-) lab evidence of respiratory failure (arterial blood gases) : • pO2 less than 70mmHg • O2 saturation less than 92% • pCO2 greater than 45mmHg • pH arterial less than 7.35 • pH arterial greater than 7.45 • CO2 greater than 30mmol/L • Respiratory rate greater than 24 (tachypnea) • FiO2 greater than 32% • HCO3 greater than 26 mEq/L (+/-) clinical evidence of acute OR chronic respiratory failure : • Shortness of breath • Intubation • Dyspnea • Tachypnea • Supplemental oxygen therapy (+/-) coexisting diagnoses : • Pneumonia • Asthma • Cystic fibrosis • Chronic obstructive pulmonary disease (COPD) • Chronic lung disease • Neoplasm of lung • Heart failure (+/-) clinical evidence of hypoxemia OR hypercapnia: • Chronic obstructive pulmonary disease • Obesity • Drug overdose • Head injury • Acute respiratory distress syndrome • Asthma • Pneumonia (+/-) documentation of high flow oxygen Satisfying evidence: Documentation of respiratory failure acuity: • Acute respiratory failure • Chronic respiratory failure • Acute on chronic respiratory failure	✔	✔	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 Triggering evidence: (MIN of 2 for CDI) Documentation of ventilator : • Mechanical ventilator • Positive end expiratory pressure • Pressure controlled ventilation • Volume controlled ventilation • Intermittent positive pressure ventilation • Continuous mandatory ventilation • Continuous positive airway pressure OR intubation : • Intubation • Cricothyroidotomy • Insertion of tracheostomy tube OR noninvasive respiratory support : • High flow oxygen • Continuous positive airway pressure • Bilevel positive airway pressure AND NO mention of (sleep apnea AND CPAP) AND NO mention of (intubation AND general anesthesia) Satisfying evidence: Documentation of respiratory failure: • Respiratory failure including but not limited to: • Acute respiratory failure • Chronic respiratory failure • Hypoxemic respiratory failure • Hypercapnic respiratory failure • Neonatal respiratory failure • Postprocedural respiratory failure	✔	✔	Documentation of ventilator, intubation, or noninvasive respiratory support without documentation of respiratory failure	RESPIRATORY DISORDER - C There is documentation of ventilator, intubation, or other respiratory support. Please document any associated diagnosis.	✔	✔		✔
11003 Triggering evidence: Documentation of respiratory insufficiency: • Respiratory insufficiency including but not limited to: • Respiratory insufficiency • Acute respiratory insufficiency • Chronic respiratory insufficiency • Respiratory insufficiency following shock • Respiratory insufficiency following trauma • Postprocedural respiratory insufficiency Satisfying evidence: Documentation of respiratory failure: • Respiratory failure including but not limited to: • Acute respiratory failure • Chronic respiratory failure • Hypoxemic respiratory failure • Hypercapnic respiratory failure • Neonatal respiratory failure • Postprocedural respiratory failure	✔	✔	Documentation of respiratory insufficiency without documentation of respiratory failure	RESPIRATORY INSUFFICIENCY There is documentation of respiratory insufficiency. Please document any associated diagnosis.	✔	✔	✔	✔
11004 Triggering evidence: Documentation of respiratory failure: • Respiratory failure including but not limited to: • Acute respiratory failure • Chronic respiratory failure • Hypoxemic respiratory failure • Hypercapnic respiratory failure • Neonatal respiratory failure • Postprocedural respiratory failure Satisfying evidence: Documentation of etiology of respiratory failure: • Any physician etiology linked to respiratory failure • Idiopathic respiratory failure • Multifactorial respiratory failure	✔	✔	Documentation of respiratory failure without documentation of the etiology of respiratory failure	RESPIRATORY FAILURE - ETIOLOGY Please document the etiology of respiratory failure.
11005 Triggering evidence: MIN, 2 documentation of hypoxia : • Hypoxia including but not limited to: • Hypoxia • Hypoxemia • Hypoxemic respiratory failure • Acute hypoxemic respiratory failure • Chronic hypoxemic respiratory failure AND MIN, 2 lab evidence of respiratory failure : • Lab evidence of respiratory failure • Arterial pO2 < 70 mmHg • SpO2 < 92% • Arterial pCO2 > 45 mmHg • Arterial pH < 7.35 • Arterial pH > 7.45 • CO2 > 30 mmol/L • Respiratory rate > 24 breaths/min • Arterial FiO2 > 32% • Arterial HCO3 > 26 mEq/L OR documentation of oxygen therapy: • Including but not limited to: • Documentation of high flow oxygen • Dependence on supplemental oxygen • Home oxygen therapy • Oxygen administration by nasal cannula • Supplemental oxygen for positive airway pressure treatment • Long-term oxygen therapy OR documentation of coexisting diagnoses of respiratory failure: • Asthma • Chronic obstructive pulmonary disease • Drug overdose • Head injury • Pneumonia • Pulmonary edema • Pulmonary fibrosis • Pulmonary embolism • Spinal cord injury OR clinical evidence of respiratory failure: • Cyanosis • Dyspnea • Intubation • Mechanical ventilator Satisfying evidence: Documentation of respiratory failure: • Respiratory failure including but not limited to: • Acute respiratory failure • Chronic respiratory failure • Hypoxemic respiratory failure • Hypercapnic respiratory failure • Neonatal respiratory failure • Postprocedural respiratory failure	✔	✔	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* Triggering evidence: Documentation of acute respiratory failure present on admission: • Acute respiratory failure • Acute-on-chronic respiratory failure		✔	Notification: Documentation that acute respiratory failure was present on admission
11012 Triggering evidence: Documentation of acute respiratory failure: • Acute-on-chronic respiratory failure • Acute onset respiratory failure Satisfying evidence: Clinical OR lab evidence of acute respiratory failure : • Arterial pO2 < 60 mmHg • SpO2 < 90% • Arterial pCO2 > 45 mmHg AND evidence of coexisting diagnosis: • Including but not limited to: • Brochiectasis • Chronic obstructive pulmonary disease • Congestive heart failure • Kyphoscoliosis • Pneumonia • Pulmonary fibrosis • Pulmonary embolism	✔	✔	Documentation of acute respiratory failure without clinical or lab evidence and documentation of coexisting diagnosis	ACUTE RESPIRATORY FAILURE Please document the clinical or lab indicators and any comorbities supporting the diagnosis of acute respiratory failure.		✔
11013 Triggering evidence: Documentation of acute respiratory distress AND NO documentation of respiratory distress syndrome Satisfying evidence: Documentation of acute respiratory failure	✔	✔	Documentation of acute respiratory distress without documentation of acute respiratory failure	ACUTE RESPIRATORY DISTRESS There is documentation of acute respiratory distress. Please document any associated diagnosis.	✔	✔	✔	✔
11014 Triggering evidence: Documentation of acute respiratory failure : • Acute-on-chronic respiratory failure • Acute respiratory failure Satisfying evidence: Documentation of acute respiratory failure present on admission status OR Documentation of the presence of acute respiratory failure on the history and physical document OR Documentation of negated acute respiratory failure on the history and physical document	✔	✔	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 Triggering evidence: Documentation of respiratory failure : • Respiratory failure including but not limited to: • Acute respiratory failure • Chronic respiratory failure • Hypoxemic respiratory failure • Hypercapnic respiratory failure • Neonatal respiratory failure • Postprocedural respiratory failure OR documentation of respiratory distress : • Respiratory distress including but not limited to: • Acute respiratory distress • Acute respiratory distress in newborn • Respiratory distress syndrome OR lab evidence of respiratory failure: • pH < 7.35 • pCO2 > 50 mmHg • pO2 < 60 mmHg AND NO documentation of respiratory distress syndrome for age < 28 days old (+/-) clinical evidence of acute OR chronic respiratory failure: • Including but not limited to: • Cyanosis • Intubation • Hypoxemia • Continuous home oxygen supply • Supplemental oxygen therapy Satisfying evidence: Documentation of hypoxemic OR hypercapnic respiratory failure with acuity: • Including but not limited to: • Hypercapnic respiratory failure • Hypoxemic respiratory failure • Acute hypercapnic respiratory failure • Acute hypoxemic respiratory failure • Chronic hypercapnic respiratory failure • Chronic hypoxemic respiratory failure • Acute hypoxemic respiratory failure co-occurrent with acute hypercapnic respiratory failure	✔	✔	Documentation of respiratory distress or respiratory failure or lab evidence of respiratory failure (+/- clinical evidence of acute or chronic respiratory failure) without documentation of type and acuity	RESPIRATORY DISORDER - B There is documentation or evidence of respiratory disorder, please document the type and acuity of respiratory disorder.	✔	✔
11016 Triggering evidence: SF ratio < 235 OR PF ratio < 200 OR PF ratio 200-300 OR SF ratio 235-315 Satisfying evidence: Documentation of acute lung injury OR acute respiratory distress syndrome OR acute respiratory failure	✔	✔	Documentation of abnormal SpO2/FiO2 or PaO2/FiO2 ratio without documentation of acute lung injury, acute respiratory distress syndrome, or acute respiratory failure	SF OR PF RATIO There is evidence of abnormal P/F or S/F ratio. Please document any associated diagnosis.	✔	✔	✔	✔
51001683^L Triggering evidence: Documentation of clinical evidence of respiratory failure : • Hypoxemia • Cyanosis • Dyspnea • Intubation • Tachypnea AND documentation of supplemental oxygen: • Endotracheal tube • Intubation • Oxygen administration by nasal cannula • Oxygen mask • Oxygen therapy • Ventilator AND documentation of respiratory failure : • Acute respiratory failure • Chronic respiratory failure • Hypoxemic respiratory failure • Hypercapnic respiratory failure • Neonatal respiratory failure • Postprocedural respiratory failure OR lab evidence of respiratory failure: • [requires all lab evidence from the same lab document] • pO2 arterial < 60 mmHg • pCO2 arterial > 50 mmHg • pH arterial < 7.35 Satisfying evidence: Documentation of hypoxemic OR hypercapnic respiratory failure: • Acute hypercapnic respiratory failure • Chronic hypercapnic respiratory failure • Acute-on-chronic hypercapnic respiratory failure • Acute hypoxemic respiratory failure • Chronic hypoxemic respiratory failure • Acute-on-chronic hypoxemic respiratory failure AND acuity of respiratory failure	✔	✔	Documentation of respiratory failure or lab evidence of respiratory failure and clinical evidence of acute or chronic respiratory failure, and oxygen therapy without documentation of type and acuity of respiratory failure	RESPIRATORY DISORDER - E There is documentation or evidence of respiratory disorder, please document the type and acuity of respiratory disorder.	✔	✔		✔
51002482 Triggering evidence: Documentation of acute respiratory failure Satisfying evidence: Lab evidence of respiratory failure: • pH venous <7.3 • pH arterial <7.35 • O2 sat <92% AND Clinical evidence of respiratory failure: • RR >20 • Dyspnea • Increased work of breathing • Hemodynamic instability • Slow respiration AND Treatment evidence of respiratory failure: • CPAP • BiPAP • High flow O2 • Ventilator • Nonrebreather mask • Oxygen > 4L	✔	✔	Documentation of acute respiratory failure without clinical and lab evidence of respiratory failure	RESPIRATORY FAILURE C Please include the clinical indicators supporting the diagnosis of acute respiratory failure.		✔
51002785 Triggering evidence: Documentation of respiratory failure: • Respiratory failure including but not limited to: • Acute respiratory failure • Chronic respiratory failure • Hypoxemic respiratory failure • Hypercapnic respiratory failure • Neonatal respiratory failure • Postprocedural respiratory failure Satisfying evidence: Documentation of the acuity of respiratory failure: • Acute respiratory failure • Chronic respiratory failure • Acute on chronic respiratory failure AND documentation of the presence or absence of the type of respiratory failure: • Including but not limited to: • Hypercapnic respiratory failure • Hypoxemic respiratory failure • Acute hypercapnic respiratory failure • Acute hypoxemic respiratory failure • Chronic hypercapnic respiratory failure • Chronic hypoxemic respiratory failure • Acute hypoxemic respiratory failure co-occurrent with acute hypercapnic respiratory failure	✔	✔	Documentation of respiratory failure without documentation of acuity and the presence or absence of the type of respiratory failure (age: > 28 days)	RESP FAILURE ACUITY AND TYPE There is documentation of respiratory failure. Please document the acuity and the type.	✔	✔
PedRespFailure-001^P Triggering evidence: Documentation of respiratory failure OR documentation of respiratory distress OR Lab documentation of arterial pH < 7.35 AND arterial pCO2 > 50 mmHg AND Clinical or lab evidence of hypoxia/hypoxemia: • SpO2 <=90 • O2 liter flow • PaO2 <= 60 mmHg OR Lab evidence of hypercarbia/hypercapnea: • pCO2 arterial > 50 mmHg AND pH < 7.35 • pCO2 venous > 55 mmHg AND ph < 7.3 AND clinical evidence of respiratory failure : • Including but not limited to: • Chest wall retraction • Cyanosis • Diaphragmatic breathing • Grunting respiration • Nasal flaring Satisfying evidence: Documentation of hypoxemic OR hypercapnic respiratory failure with acuity: • Acute • Chronic • Acute on chronic	✔	✔	Pediatric: Documentation or evidence of respiratory failure or respiratory distress without documentation of type and acuity	RESPIRATORY CONDITION There is documentation or evidence of respiratory disorder, please document the type and acuity of respiratory disorder.	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
4000001 Triggering evidence: Documentation of thoracentesis Satisfying evidence: Documentation of laterality of thoracentesis: • Right • Left • Bilateral AND intent of thoracentesis : • Diagnostic • Therapeutic (+/-) Documentation of presence or absence of imaging guidance: • CT • Ultrasound	✔	✔	Documentation of thoracentesis without documentation of intent and laterality of thoracentesis	THORACENTESIS Please document the laterality and intent of the thoracentesis procedure.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
5006 Triggering evidence: Documentation of chest pain Satisfying evidence: Documentation of the etiology of chest pain: • Any provider linked cause of chest pain • Idiopathic chest pain • Multifactorial chest pain	✔	✔	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 Triggering evidence: MIN,2 documentation of angina (+/-) clinical evidence of angina: • Including but not limited to: • Chest tightness • Dyspnea • Excessive sweating • Indigestion • Lightheadedness Satisfying evidence: Documentation of the type of angina: • Including but not limited to: • Stable angina • Unstable angina • Prinzmetal angina • Exercise-induced angina	✔	✔	Documentation of angina (+/- clinical evidence of angina) without documentation of the type of angina	ANGINA TYPE Please document the type of angina.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51002102 Triggering evidence: Documentation of pacemaker: • Pacemaker Satisfying evidence: Documentation of etiology of pacemaker: • Including but not limted to: • Bradyarrhythmia • Tacyarrhythmia • Long QT syndrome • AV Block • Sinus node dysfunction • Vasovagal syncope		✔	Documentation of pacemaker without documentation of etiology of pacemaker
51002262 Triggering evidence: Documentation of adenosine OR documentation of cardioversion AND procedural evidence of supraventricular tachycardia: • Reverse Trendelenburg positioning • Trendelenburg positioning • Vagal maneuver OR medication evidence of supraventricular tachycardia: • Antiarrhythmic medication • Beta blocking agent • Calcium channel blocker Satisfying evidence: Documentation of supraventricular tachycardia	✔	✔	Documentation of adenosine or cardioversion and evidence of supraventricular tachycardia without documentation of supraventricular tachycardia	ARRYTHMIA EVIDENCE There is evidence of arrythmia. Please document any associated diagnosis.	✔		✔
7001 Triggering evidence: Documentation of atrial flutter (+/-) clinical evidence of atrial flutter: • Chest pain • Dyspnea • Syncope • Palpitations • Shortness of breath • Hypotension Satisfying evidence: Documentation of type of atrial flutter: • Atrial flutter type I • Atrial flutter type II	✔	✔	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.	✔
7006 Triggering evidence: Documentation of sudden onset supraventricular tachycardia AND (+/-) clinical evidence of supraventricular tachycardia: • Chest pain • Dyspnea • Syncope • Lightheadedness • Fatigue Satisfying evidence: Documentation of paroxysmal supraventricular tachycardia	✔	✔	Documentation of supraventricular tachycardia with sudden onset (+/- clinical evidence of SVT) without documentation of paroxysmal supraventricular tachycardia	SUPRAVENTRICULAR TACHYCARDIA There is documentation and clinical evidence of sudden onset supraventricular tachycardia (SVT). Please document further specificity of the SVT.
7007 Triggering evidence: Documentation of atrioventricular (AV ) block (+/-) clinical evidence of AV block: • Dyspnea • Fatigue • Bradycardia • Abnormal heart beat (+/-) medication evidence of AV block: • Atropine • Dobutamine • Dopamine • Epinephrine • Isoproterenol Satisfying evidence: Documentation of the type of AV block: • Complete AV block • Partial AV block	✔	✔	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.	✔		✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
7000 Triggering evidence: Documentation of atrial fibrillation : • Chest pain • Dizziness • Dyspnea • Tachycardia • Near syncope (+/-) clinical evidence of atrial fibrillation: • Chest pain • Dizziness • Dyspnea • Tachycardia • Near syncope Satisfying evidence: Documentation of type of atrial fibrillation : • Chronic atrial fibrillation • Paroxysmal atrial fibrillation • Persistent atrial fibrillation • Permanent atrial fibrillation	✔	✔	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.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
7009 Triggering evidence: Documentation of cardiac arrest (+/-) clinical evidence cardiac arrest: • Absent pulse • Apnea • Loss of consciousness • Unconscious Satisfying evidence: Documentation of etiology of cardiac arrest: • Any provider linked cause of cardiac arrest • Idiopathic cardiac arrest • Multifactorial cardiac arrest	✔	✔	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.		✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51002142 Triggering evidence: Documentation of heart failure AND NO documentation of hypertension OR coronary artery disease Satisfying evidence: Documentation of cardiomyopathy	✔	✔	Documentation of heart failure and no documentation of HTN or CAD without documentation of the presence or absence of cardiomyopathy	HEART FAILURE - C There is documentation of heart failure and no documentation of hypertension or coronary artery disease. Please document any associated diagnosis.
7002 Triggering evidence: Documentation of cardiomyopathy AND (+/-) clinical evidence of cardiomyopathy: • Acute edema • Angina • Atrial fibrillation • Tachycardia • Dyspnea Satisfying evidence: Documentation of the type of cardiomyopathy: • Hypertrophic cardiomyopoathy • Restrictive cardiomyopoathy • Dilated cardiomyopoathy • Arrhythmogenic cardiomyopoathy	✔	✔	Documentation of cardiomyopathy (+/- clinical evidence of cardiomyopathy) without documentation of the type of cardiomyopathy	CARDIOMYOPATHY Please document the type of cardiomyopathy.	✔			✔
7011 Triggering evidence: Documentation of cardiomyopathy (+/-) clinical evidence of cardiomyopathy: • Chest pain • Acute edema • Angina • Atrial fibrillation • Cough Satisfying evidence: Documentation of type of cardiomyopathy : • Hypertrophic cardiomyopathy • Arrhythmogenic cardiomyopathy • Dilated cardiomyopathy • Diabetic cardiomyopathy • Restrictive cardiomyopathy AND documentation of the presence or absence of heart failure	✔	✔	Documentation of cardiomyopathy (+/- clinical evidence of cardiomyopathy) without documentation of the type of cardiomyopathy and the presence or absence of heart failure	CARDIOMYOPATHY - B Please document the type of cardiomyopathy and the presence or absence of any associated heart conditions.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
400001^P Triggering evidence: Documentation of cardiovascular congenital condition Satisfying evidence: Documentation of type of congenital cardiovascular disorder: • Including but not limited to: • Tetralogy of Fallot • Aortic valve stenosis • Atrial septal defect • Patent ductus arteriosus • Coarctation of aorta	✔	✔	Pediatric: Documentation of congenital heart disease without documentation of the type of congenital heart disease	CONGENITAL CARDIOVASCULAR DISORDER Please document the type of cardiovascular congenital condition.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
29004 Triggering evidence: Documentation of deep venous thrombosis (DVT) Satisfying evidence: Documentation of DVT with acuity : • Acute deep venous thrombosis • Chronic deep venous thrombosis AND DVT with laterality : • Right • Left • Bilateral	✔	✔	Documentation of DVT without documentation of the acuity and laterality of DVT	DVT Please document the acuity and laterality of the DVT.	✔		✔
29005 Triggering evidence: Documentation of DVT Satisfying evidence: Documentation of DVT site	✔	✔	Documentation of DVT without documentation of the site of DVT	DVT SITE Please document the site of the DVT.	✔		✔
29011 Triggering evidence: Documentation of deep venous thrombosis (DVT) Satisfying evidence: Documentation of DVT present on admission status OR documentation of the presence of DVT on the history and physical document OR documentation of negated DVT on the history and physical document	✔	✔	Documentation of DVT without documentation of present on admission status	DVT POA Please document whether the DVT was present on admission.	✔
29012 Triggering evidence: Documentation of venous thromboembolism Satisfying evidence: Documentation of venous thromboembolism present on admission status OR Documentation of the presence of venous thromboembolism on the history and physical document OR Documentation of negated venous thromboembolism on the history and physican document	✔	✔	Documentation of venous thromboembolism without documentation of present on admission status	VENOUS THROMBOEMBOLISM POA Please document whether venous thromboembolism was present on admission.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
10000 Triggering evidence: Documentation of heart failure AND lab evidence of heart failure: • BNP/ Pro BNP > 500 OR clinical evidence of heart failure: • Hypertension • Diastolic dysfunction • Systolic dysfunction • Hypertrophic cardiomyopathy • Ventricular hypertrophy • EF <= 40% OR medication evidence of heart failure: • Calcium Channel Blockers • ACE Inhibitors • Angiotensin II Receptor Blockers • Diuretics OR evidence of acuity: • Ascites • Peripheral edema • Jugular vein distention • Difficult breathing • Oxygen use • Pulmonary edema • Diuretics given IV AND NO documentation of acute cor pulmonale Satisfying evidence: Documentation of systolic OR diastolic heart failure : • Including but not limited to: • Systolic heart failure • Systolic and diastolic heart failure • Diastolic heart failure • Heart failure with preserved ejection fraction • Heart failure with reduced ejection fraction AND documentation of acuity of heart failure: • Acute Systolic heart failure • Acute Systolic and diastolic heart failure • Acute Diastolic heart failure • Chronic Systolic heart failure • Chronic Systolic and diastolic heart failure • Chronic Diastolic heart failure • Acute on chronic Systolic heart failure • Acute on chronic Systolic and diastolic heart failure • Acute on chronic Diastolic heart failure (+/-) documentation of grade of heart failure: • NYHA classification	✔	✔	Documentation of heart failure and clinical, lab, medication or echo evidence of heart failure without documentation of the type and acuity of heart failure	HEART FAILURE Please document the type and acuity of heart failure.	✔	✔
10003^A Triggering evidence: Documentation of acute heart failure: • Including but not limited to: • Acute heart failure • Exacerbation of congestive heart failure • Decompensated heart failure Satisfying evidence: Evidence of acuity of heart failure: • BNP/ ProBNP > 500 • Diuretics given IV • Pulmonary edema • Ascites • Peripheral edema • Jugular vein distention • Difficult breathing • Use of oxygen	✔	✔	Documentation of acute heart failure without clinical, lab, medication, or radiologic evidence of acute heart failure (age: > 18 years)	ACUTE HEART FAILURE Please include the clinical indicatiors supporting the diagnosis of acute heart failure.		✔
10005^A Triggering evidence: Documentation of systolic heart failure: • Including but not limited to: • Systolic heart failure • Systolic and diastolic heart failure • Heart failure with reduced ejection fraction Satisfying evidence: Evidence of systolic heart failure: • EF <= 40% • Calcium Channel Blockers • ACE Inhibitors • Angiotensin II Receptor Blockers • Diuretics • Systolic dysfunction • Left ventricular systolic dysfunction • Coronary arteriosclerosis	✔	✔	Documentation of systolic heart failure without clinical, echo, or medication evidence of systolic heart failure (age: > 18 years)	SYSTOLIC HEART FAILURE Please include the clinical indicators supporting the diagnosis of systolic heart failure.	✔	✔
10006^A Triggering evidence: Documentation of diastolic heart failure: • Including but not limited to: • Diastolic heart failure • Systolic and diastolic heart failure • Heart failure with normal ejection fraction Satisfying evidence: Evidence of diastolic heart failure: • EF > 40% • Normal EF • Hypertrophic cardiomyopathy • Ventricular hypertrophy • Hypertension • Diastolic dysfunction • Aortic valve stenosis	✔	✔	Documentation of diastolic heart failure without clinical or echo evidence of diastolic heart failure (age: > 18 years)	DIASTOLIC HEART FAILURE Please include the clinical indicators supporting the diagnosis of diastolic heart failure.	✔	✔
10007* Triggering evidence: Documentation of cor pulmonale : • Including but not limited to: • Chest pain • Cough • Cyanosis • Edema • Nausea • Wheezing • Lightheadedness (+/-) clinical evidence of cor pulmonale: • Including but not limited to: • Chest pain • Cough • Cyanosis • Edema • Nausea • Wheezing • Lightheadedness		✔	Notification: Documentation of cor pulmonale (+/- clinical evidence of cor pulmonale)
10008 Triggering evidence: Documentation of heart failure Satisfying evidence: Documentation of systolic OR diastolic heart failure: • Including but not limited to: • Systolic heart failure • Diastolic heart failure • Systolic and diastolic heart failure • Heart failure with normal ejection fraction • Heart failure with reduced ejection fraction	✔	✔	Documentation of heart failure without documentation of the type of heart failure	HEART FAILURE SPECIFICITY Please document the type of heart failure.	✔	✔
10010 Triggering evidence: Documentation of heart failure Satisfying evidence: Documentation of the etiology of heart failure: • Including but not limited to: • Acute cor pulomonale • Heart failure post surgery • Hypertension • Rheumatic heart disease	✔	✔	Documentation of heart failure without documentation of the etiology of heart failure	HEART FAILURE - ETIOLOGY Please document the etiology of heart failure, if known.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
420001^P Triggering evidence: Evidence of diatolic blood pressure >80 mmHg AND MIN,2 evidence of systolic blood pressure >120 mmHg AND Evidence of antihypertensive medications: • Including but not limited to: • Ace inhibitor • Beta-blocking • Calcium channel blocking • Angiotensin II receptor blocker • Diuretics AND NO documentation of pregnancy induced hypertension Satisfying evidence: Documentation of elevated blood pressure OR stage of hypertension: • Explicit elevated BP • Hypertension stage 1 • Hypertension stage 2 • Hypertensive emergency • Hypertensive urgency	✔	✔	Pediatric: Evidence of hypertension without documentation of elevated blood pressure or stage of hypertension (age: > 1 year)	ELEVATED BLOOD PRESSURE There is evidence of elevated systolic and diastolic blood pressure readings with evidence of antihypertensive medications. Please document any associated diagnosis.				✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
18008 Triggering evidence: Documentation of accelerated hypertension OR malignant hypertension Satisfying evidence: Documentation of hypertensive emergency, hypertensive crisis OR hypertensive urgency	✔	✔	Documentation of accelerated or malignant hypertension without documentation of hypertensive urgency, emergency, or crisis	HYPERTENSION TYPE - B Please document the type of hypertension.	✔
18010^A Triggering evidence: Medication evidence of IV or STAT antihypertensives: • Including but not limited to: • Angiotensin II receptor blocker • Beta-blockers • Calcium channel blocker • Diuretics • Alpha blockers AND MIN,2 evidence of hypertensive urgency: • Diastolic BP > 110 mmHg • Systolic BP > 180 mmHg (+/-) documentation of hypertension: • Including but not limited to: • Essential hypertension • Hypertension • Malignant hypertension • Neonatal hypertension • Pregnancy induced hypertension • Satisfying evidence: Documentation of hypertensive emergency, hypertensive crisis OR hypertensive urgency	✔	✔	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.	✔
51002182 Triggering evidence: Clinical evidence of hypertensive emergency: • Systolic BP >180 • Diastolic BP >120 AND medication evidence of IV antihypertensive: • Angiotensin II receptor blocker • Beta-blockers • Calcium channel blocker • Diuretics • Alpha blockers AND documentation of organ involvement: • Acute renal failure • Heart failure • Intracranial hemorrhage • Seizure • Cerebrovascular accident • Myocardial infarction Satisfying evidence: Documentation of hypertensive emergency	✔	✔	Clinical evidence of hypertensive emergency and medication evidence of an IV antihypertensive and organ involvement without documentation of hypertensive emergency	ELEVATED BLOOD PRESSURE - C There is documentation of elevated blood pressure, IV antihypertensive medications, and organ involvement. Please document any associated diagnosis.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
5000^A Triggering evidence: Documentation of acute coronary syndrome OR Documentation of EKG changes: • ST segement changes • Inverted T wave • ST elevation AND Lab evidence of acute coronary syndrome: • Troponin T greater than 0.01 ng/mL • Troponin I greater than 0.03 ng/mL (+/-) Clinical evidence of acute coronary syndrome: • Chest pain • Dyspnea • Indigestion • Shortness of breath • Sweating Satisfying evidence: Documentation of the type of ACS: • Myocardial infarction • Aborted myocardial infarction • STEMI • NSTEMI • Angina	✔	✔	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 any associated diagnosis.	✔	✔		✔
5001 Triggering evidence: MIN,2 Documentation of myocardial infarction (+/-) clinical evidence of MI: • Fatigue • Chest pain • Clammy skin • Jaw pain (+/-) evidence of EKG changes: • Electrocardiographic ST segment changes • Inverted T wave • ST elevation (+/-) lab evidence of MI: • Creatinine • Troponin Satisfying evidence: Documentation of STEMI, NSTEMI, or aborted MI	✔	✔	Documentation of MI (+/- clinical, EKG, or lab evidence of MI) without documentation of STEMI, NSTEMI, or aborted MI	MYOCARDIAL INFARCTION Please document the type of MI.	✔	✔		✔
5003* Triggering evidence: Documentation of possible myocardial infarction (+/-) clinical evidence of MI: • Including but not limited to: • Burning sensation • Chest pain • Clammy skin • Jaw pain • Pain radiating to left arm (+/-) evidence of EKG changes: • Inverted T wave • Nonspecific ST-T abnormality • ST segment depression • ST segment elecation (+/-) lab evidence of MI: • CK • CKMB • Troponin I • Troponin T		✔	Notification: Documentation of possible MI (+/-clinical, EKG, or lab evidence of MI)
5008 Triggering evidence: Documentation of MI OR documentation of STEMI OR NSTEMI (+/-) evidence of ACS: • Chest pain • Clammy skin • Dizziness • Heartburn • Dyspnea Satisfying evidence: Documentation of type of STEMI OR NSTEMI: • Acute non-Q wave MI • Acute Q wave MI • Acute NSTEMI • Subsequent NSTEMI • Acute STEMI • Subsequent STEMI	✔	✔	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 Triggering evidence: Documentation of STEMI : • Acute ST segment elevation myocardial infarction • Acute Q wave myocardial infarction • Subsequent ST segment elevation myocardial infarction (+/-) Clinical evidence of ACS: • Including but not limited to: • Chest pain • Myocardial ischemia • Abnormal precordial pulsation • Excessive sweating • Jaw pain Satisfying evidence: Documentation of site of STEMI: • Actue ST segment elevation myocardial infarction • Any provider linked site of STEMI AND NO documentation of site entire heart OR entire myocardium	✔	✔	Documentation of STEMI (+/- clinical evidence of ACS) without documentation of the STEMI site	STEMI Please document the site of the STEMI.		✔
5010^A Triggering evidence: Documentation of Type 2 MI OR Documentation of Type 2 STEMI : • Acute ST segment elevation myocardial infarction OR Documentation of Type 2 NSTEMI: • Acute non-ST segment elevation myocardial infarction • Subsequent non-ST segment elevation myocardial infarction (+/-) Clinical evidence of ACS: • Including but not limited to: • Chest pain • Myocardial ischemia • Abnormal precordial pulsation • Excessive sweating • Jaw pain Satisfying evidence: Documentation of the etiology of Type 2 STEMI, NSTEMI OR MI: • Anemia • Cardiac arrhythmia • Coronary artery embolism • Hypertension • Hypotention OR Documentation of the cause of Type 2 MI: • Any provider linked cause of Type 2 MI OR Documentation of the cause of Type 2 NSTEMI: • Any provider linked cause of Type 2 NSTEMI OR Documentation of the cause of Type 2 STEMI: • Any provider linked cause of Type 2 STEMI	✔	✔	Documentation of Type 2 MI (+/- clinical evidence of ACS) without documentation of the etiology of Type 2 MI (age: > 18 years)	MYOCARDIAL INFARCTION ETIOLOGY Please document the underlying etiology of the type 2 MI, if known.		✔
5011* Triggering evidence: Documentation of demand ischemia (+/-) clinical evidence of ACS: • Including but not limited to: • Dizziness • Chest pain • Clammy skin • Fatigue • Lightheadedness		✔	Notification: Documentation of demand ischemia (+/- clinical evidence of ACS)
51002382 Triggering evidence: Documentation of coronary artery disease AND documentation of chest pain AND evidence of medication treatment of NSTEMI or STEMI: • Including but not limited to: • Aspirin • Beta blockers • Heparin • Ranexa • Nitrates AND NO etiology of chest pain other than NSTEMI or STEMI Satisfying evidence: Documentation of presence or absence of NSTEMI or STEMI		✔	Documentation of coronary artery disease, chest pain and evidence of medication treatment without documentation of NSTEMI or STEMI
ACS-001^A Triggering evidence: Documentation of acute coronary syndrome NO documentation of negated ACS Satisfying evidence: Documentation of type of acute coronary syndrome: • Myocardial infarction • Aborted myocardial infarction • Angina	✔	✔	Documentation of ACS without documentation of the type of ACS (age: > 18 years)	ACUTE CORONARY SYNDROME - B Please document the type of actue coronary syndrome.	✔	✔		✔
ACS-002 Triggering evidence: Documentation of demand ischemia Satisfying evidence: Documentation of the etiology of demand ischemia: • Anemia • Infectious disease • Overexertion • Tachycardia • Any provider linked cause of demand ischemia • Idiopathic demand ischemia • Multifactorial demand ischemia	✔	✔	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 Triggering evidence: Documentation of NSTEMI: • Acute non-Q wave myocardial infarction • Acute non-ST segment elevation myocardial infarction • Subsequent non-ST segment elevation myocardial infarction Satisfying evidence: Evidence of NSTEMI EKG changes: • Inverted T wave • Deep symmetric anterior T wave inverison • ST segment depression OR evidence of NSTEMI biomarkers: • Abnormal cardiac enzymes • Creatine kinase • Troponin OR clinical evidence of NSTEMI: • Chest pain • Clammy skin • Dyspnea • Jaw pain • Lightheadedness	✔	✔	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.		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12023 Triggering evidence: Documentation of ischemic extremity OR MIN 3, clinical evidence of ischemic extremity : • Including but not limited to: • Absent pulse • Discoloration of skin • Cold extremity • Intermittent claudication • Necrosis (+/-) history of medical conditions : • Including but not limited to: • Arteriosclerosis • DVT • Neuropathy • Diabetes Mellitus • PVD (+/-) diagnostic tests: • Including but not limited to: • Doppler ultrasonography • Ankle brachial pressure index (+/-) social history for smoking Satisfying evidence: Documentation of etiology of the ischemic extremity: • Vascular insufficiency of limb • Deep venous thrombosis • Aneurysm of femoral artery • Venous embolism • Thrombophlebitis of lower extremity	✔	✔	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 Please document the etiology of limb ischemia	✔
430001^P Triggering evidence: Evidence of low diastolic BP: • <3 mons, Diastolic BP <35 • >= 3 mons and <6 mons, Diastolic BP <50 • >= 6 mons and <1 year, Diastolic BP <55 • >= 1 year and <6 years, Diastolic BP <55 • >=6 and <12, Diastolic BP <60 • >=12, Diastolic BP <65 AND Evidence of pediatric systolic hypotension: • <1 month, SBP <60 • 1 month to <1 year, SBP <70 • 1 year to <2 years, SBP <72 • 2 years to <3 years, SBP <74 • 3 years to <4 years, SBP <76 • 4 years to <5 years, SBP <78 • 5 years to <6 years, SBP <80 • 6 years to <7 years, SBP <82 • 7 years to <8 years, SBP <84 • 8 years to <9 years, SBP <86 • 9 years to <10 years, SBP <88 • 10 years to <19 years, SBP <90 Satisfying evidence: Documentation of hypotension: • Hypotension • Iatrogenic hypotension	✔	✔	Pediatric: Clinical evidence of hypotension without documentation of hypotension	PEDIATRIC LOW BLOOD PRESSURE There is evidence of low blood pressure. Please document any associated diagnosis.				✔
51001186 Triggering evidence: Documentation of peripheral vascular disease (PVD) Satisfying evidence: Documentation of atherosclerosis	✔	✔	Documentation of peripheral vascular disease without documentation of atherosclerosis	PERIPHERAL VASCULAR DISEASE There is documentation of PVD. Please document any associated diagnosis.	✔			✔
51001382^A Triggering evidence: Documentation of volume overload (+/-) clinical evidence of volume overload: • Edema • High blood pressure • Shortness of breath • Weight gain Satisfying evidence: Documentation of the etiology of volume overload: • Any physician documented cause of volume overload • Multifactorial • Idiopathic	✔	✔	Documentation of volume overload (+/- clinical evidence of volume overload) without documentation of etiology of volume overload (age: >18 years)	VOLUME OVERLOAD There is documentation of volume overload. Please document etiology of volume overload.
51001762 Triggering evidence: MIN,2 Documentation of heart valve disorder Satisfying evidence: Documentation of rheumatic OR non-rheumatic etiology of heart valve disorder	✔	✔	Documentation of a heart valve disorder without documentation of rheumatic or non-rheumatic etiology	VALVE DISORDER - B Please document etiology of the heart valve disorder.	✔
51001982 Triggering evidence: Documentation of endocarditis Satisfying evidence: Documentation of etiology of endocarditis: • Any provider linked cause of endocarditis • Acute infective endocarditis • Bacterial endocarditis • Viral endocarditis • Nonbacterial thrombotic endocarditis	✔	✔	Documentation of endocarditis without documentation of etiology	ENDOCARDITIS - E Please document the etiology of endocarditis.	✔	✔	✔	✔
51002602 Triggering evidence: Provider documentation of nonviable tissue OR necrotic tissue AND No documentation of pregnancy with documentation of nonviable Satisfying evidence: Provider documentation of gangrene	✔	✔	Provider documentation of nonviable or necrotic tissue without documentation of the presence or absence of gangrene	UNSPECIFIED CLINICAL CONDITION - I There is provider documentation of nonviable tissue or necrotic tissue. Please document associated diagnosis.	✔	✔		✔
7004 Triggering evidence: Documentation of mitral valve disorder (+/-) clinical evidence of mitral valve disorder: • Edema • Fatigue • Syncope • Heart murmur • Orthopnea Satisfying evidence: Documentation of type of mitral valve disorder: • Mitral valve regurgitation • Mitral cusp prolapse • Mitral and aortic incompetence • Mitral stenosis with insufficiency	✔	✔	Documentation of a mitral valve disorder (+/- clinical evidence of a mitral valve disorder) without documentation of the type of mitral valve disorder	MITRAL VALVE DISORDER Please document the type of mitral valve disorder.
7005 Triggering evidence: Documentation of aortic, tricuspid OR pulmonary valve disorder (+/-) clinical evidence of a valve disorder: • Including but not limited to: • Acute edema • Syncope • Heart murmur • Shortness of breath • Fatigue Satisfying evidence: Documentation of valve stenosis OR valve stenosis with insufficiency	✔	✔	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 Triggering evidence: Documentation of pericardial effusion Satisfying evidence: Documentation of the etiology of pericardial effusion: • Congenital pericardial effusion • Pericardial effusion due to malignant neoplasm of pericardium • Pericarditis secondary to Mulibrey nanism • Any provider linked cause of pericardial effusion • Idiopathic pericardial effusion • Multifactorial pericardial effusion	✔	✔	Documentation of pericardial effusion without documentation of etiology	PERICARDIAL EFFUSION - ETIOLOGY Please document the etiology of pericardial effusion, if known.	✔			✔
OtherCirc-002 Triggering evidence: Documentation of aortic valve stenosis (+/-) evidence of aortic valve stenosis: • Including but not limited to: • Angina • Chest pain • Dyspnea on exertion • Heart murmur • Palpitations Satisfying evidence: Documentation of the etiology of aortic valve stenosis: • Congenital stenosis of aortic valve • Rheumatic aortic stenosis • Non-rheumatic aortic stenosis • Any provider linked cause of aortic valve stenosis • Idiopathic aortic valve stenosis • Multifactorial aortic valve stenosis	✔	✔	Documentation of aortic valve stenosis without documentation of the etiology of aortic valve stenosis	AORTIC VALVE STENOSIS - ETIOLOGY Please document the etiology of aortic valve stenosis, if known.	✔	✔
OtherCirc-003 Triggering evidence: MIN,2 Clincal evidence of endocarditis: • Chest pain on breathing • Heart murmur • Osler's node (hand or foot) • Splenomegaly • Muscle or joint pain AND Cardiac or noncardiac risk factors of endocarditis: • Cardiac implant • Heart valve disorder • Immunosupression • IV drug user • Central venous catheters Satisfying evidence: Documentation of endocarditis AND documentation of the etiology of endocarditis: • Any provider linked cause of endocarditis • Acute infective endocarditis • Bacterial endocarditis • Viral endocarditis • Nonbacterial thrombic endocarditis • Idiopathic endocarditis • Multifactorial endocarditis		✔	Clinical evidence of endocarditis and cardiac or noncardiac risk factors without documentation of endocarditis and the etiology of endocarditis		✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
50101 Triggering evidence: MIN,2 medication evidence of vasopressors: • Dobutamine • Dopamine • Epinephrine • Phenylephrine • Vasopressin AND MIN,2 clinical evidence of hypotension: • Mean arterial pressure (MAP) < 65mmHg • Systolic blood pressure (SBP) < 90 mmHg (+/-) documentation of hypotension (+/-) documentation of shock Satisfying evidence: Documentation of the type of shock: • Cardiogenic shock • Hypovolemic shock • Hemorrhagic shock • Neurogenic shock • Septic shock	✔	✔	Medication evidence of a vasopressor and clinical evidence of hypotension (+/- documentation 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 Triggering evidence: Documentation of hemorrhagic shock Satisfying evidence: Documentation of hypovolemic shock	✔	✔	Documentation of hemorrhagic shock without documentation of hypovolemic shock	HEMORRHAGIC SHOCK Hemorrhagic shock has been documented. Please document any additional diagnosis.		✔		✔
50103 Triggering evidence: Documentation of shock Satisfying evidence: Documentation of type of shock: • Any provider linked cause of shock	✔	✔	Documentation of shock without documentation of the etiology or type of shock	SHOCK Please document the type of shock.	✔	✔		✔
51001427^A Triggering evidence: Documentation of SBP < 90 mmHg AND Documentation of vasopressor: • Dobutamine • Dopamine • Epinephrine OR Documentation of SBP < 90 mmHg AND Documentation of blood product administration Satisfying evidence: Documentation of the type of shock: • Cardiogenic shock • Neurogenic shock • Hypovolemic shock • Hemorrhagic shock • Septic shock	✔	✔	Documentation of SBP < 90 mmHg and vasopressor or documentation of SBP < 90 mmHg and blood product administration without documentation of the type of shock	HYPOTENSION AND TREATMENT There is documentation of hypotension and vasopressor or hypotension and administration of blood products. Please document any associated condition and type.	✔	✔	✔	✔
51001463^P Triggering evidence: Documentation of pediatric systolic hypotension parameters AND Documentation of vasopressor : • Dobutamine • Dopamine • Epinephrine OR Documentation of pediatric systolic hypotension parameters AND Documentation of blood product administration Satisfying evidence: Documentation of the type of shock: • Cardiogenic shock • Neurogenic shock • Hypovolemic shock • Hemorrhagic shock • Septic shock	✔	✔	Pediatric: Documentation of pediatric systolic hypotension and vasopressor or documentation of pediatric systolic hypotension and blood product administration without documentation of type of shock	HYPOTENSION AND TREATMENT - B There is documentation of pediatric systolic hypotension and vasopressor or pediatric systolic hypotension and blood product. Please document any associated condition and type.				✔
PedShock-001^P Triggering evidence: MIN,2 Lactate greater than 4 OR peripheral pulses +1 OR documentation of hypotension OR documentation of lactic acidosis OR capillary refill greater than 2 seconds OR documentation of administration of IV fluids/bolus: • Normal saline • Lactated ringer's solution AND systolic blood pressure hypotension: • Systolic blood pressure based on age parameters (+/-) documentation of vasopressors: • Dobutamine • Dopemine • Epinephrine • Vasopressin (+/-) documentation of transfusion: • Blood product • Whole blood product • Red blood product Satisfying evidence: Documentation of the presence or absence of shock	✔	✔	Pediatric: Lab or clinical evidence of shock (+/- evidence of transfusion or vasopressor) without documentation of shock	UNSPECIFIED CLINICAL CONDITION - M There is evidence of hypotension and lab and/or clinical evidence of organ dysfunction. Please document any associated diagnosis.	✔	✔	✔	✔
Shock-001^A^L Triggering evidence: MIN,2 Evidence of hypotension : • SBP <90 • MAP <65 AND documentation of hypotension OR evidence of blood transfusion OR documentation of IV fluid administration: • Sodium chloride • Lactated ringer's solution OR documentation of vasopressor administration: • Dobutamine • Dopamine • Epinephrine • Vasopressin OR lactate > 4mmol/L (+/-) evidence of abnormal labs: • Bilirubin > 2mg/dl • Platelets < 100,000 • INR > 1.5 with no anticoagulant medication • aPTT > 60 seconds with no anticoagulant medication • Creatinine > 2 with no renal failure (+/-) documentation of altered mental status (+/-) documentation of encephalopathy Satisfying evidence: Documentation of type of shock: • Hypovolemic shock • Anaphylactic shock • Septic shock • Neurogenic shock • Cardiogenic shock	✔	✔	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.	✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12001 Triggering evidence: Documentation of syncope: • Including but not limited to: • Syncope • Syncope and collapse • Hypotensive syncope • Vasovagal syncope Satisfying evidence: Documentation of the etiology of syncope: • Including but not limited to: • Any physician etiology linked to syncope • Syncope due to orthostatic hypotension • Idiopathic syncope • Multifactorial syncope	✔	✔	Documentation of syncope without documentation of the etiology of syncope	SYNCOPE Please document the etiology of syncope, if known.				✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12026 Triggering evidence: Documentation of clostridium difficile colitis Satisfying evidence: Documentation of clostridium difficile colitis present on admission status OR documentation of clostridium difficile colitis on history and physical document OR documentation of negated clostridium difficile colitis on history and physical document	✔	✔	Documentation of clostridium difficile colitis without documentation of present on admission status	CLOSTRIDIUM DIFFICILE COLITIS POA Please document whether or not clostridium difficile colitis was present on admission.	✔
12029 Triggering evidence: Documentation of clostridium difficile colitis Satisfying evidence: Documentation of clostridium difficile diarrhea OR infection	✔	✔	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.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12024 Triggering evidence: Documentation of gastrointestinal (GI) bleed (+/-) evidence of GI bleed: • Hematemesis • Coffee ground vomiting • Melena • Blood in feces • Hematochezia Satisfying evidence: Documentation of etiology of GI bleed: • Gastritis • Colitis • Hemophilia • Celiac disease • Peptic ulcer • Idiopathic GI bleed • Multifactorial GI bleed • Any physician linked etiology of GI bleed	✔		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 Triggering evidence: Documentation of gastrointestinal (GI) ulcer : • Gastric ulcer • Peptic ulcer • Ulceration of small intestine • Duodenal erosion • Ileal ulcer (+/-) evidence of GI ulcer : • Melena • Hematochezia • Hematemesis • Burning epigastric pain • Abdominal bloating Satisfying evidence: Documentation of gastrointestinal ulcer present on admission status OR documentation of the presence of a gastrointestinal ulcer on the history and physical document OR documentation of negated gastrointestinal ulcer on the history and physical document	✔	✔	Documentation of a gastrointestinal ulcer (+/- clinical evidence of a gastrointestinal ulcer) without documentation of present on admission status	GI ULCER POA Please document whether or not the gastrointestinal ulcer was present on admission.
51003023^A^L Triggering evidence: Documentation of a gastrointestinal disorder: • Gastritis • Duodenitis • Diverticulosis AND lab evidence of a drop in hemoglobin greater than or equal to 3: • [Requires lab evidence from lab documents] Satisfying evidence: Documentation of a gastrointestinal hemorrhage	✔	✔	Documentation of a gastrointestinal disorder and lab evidence of a drop in hemoglobin without documentation of a gastrointestinal hemorrhage	GI DISORDER AND HGB There is documentation of a gastrointestinal disorder and a drop in hemoglobin. Please document any associated diagnosis.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12000 Triggering evidence: Documentation of abdominal OR pelvic pain: • Abdominal pain • Acute pelvic pain • Left upper quadrant pain • Burning epigastric pain • Rebound tenderness of epigastrium Satisfying evidence: Documentation of cause of abdominal OR pelvic pain: • Peptic ulcer • Kidney stone • Peliosis hepatis • Pancreatitis • Hiatal hernia • Idiopathic abdominal or pelvic pain • Multifactorial abdominal or pelvic pain • Any physician linked abdominal or pelvic pain	✔		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 Triggering evidence: MIN 2, Documentation of dysphagia: • Chronic epiglottitis • Neoplasm of esophagus • Semantic dementia • Alzheimer's disease • Xerostomia • Parkinson's disease Satisfying evidence: Documentation of etiology of dysphagia: • Esophagitis • Dementia • Traumatic brain injury • Cerebrovascular disease • Parkinson's disease • Idiopathic dysphagia • Multifactorial dysphagia • Any physician linked etiology	✔	✔	Documentation of dysphagia without documentation of the etiology of dysphagia	DYSPHAGIA Please document the etiology of dysphagia, if known.				✔
12010 Triggering evidence: MIN 2, Documentation of dysphagia: • Dysphagia including but not limited to: • Pharyngoesophageal dysphagia • Psychogenic dysphagia • Dysphagia lusoria • Dysphagia due to and following non-traumatic intracerebral hemorrhage • Intermittent dysphagia Satisfying evidence: Documentation of the anatomical site OR phase of the dysphagia: • Pharyngeal dysphagia • Esophageal dysphagia • Oropharyngeal dysphagia • Pharyngoesophageal phase dysphagia • Oral phase dysphagia	✔	✔	Documentation of dysphagia without documentation of the site or phase of dysphagia	DYSPHAGIA - SITE Please document the site or phase affected by dysphagia.
2003001 Triggering evidence: Documentation of peritonitis AND evidence of abscess OR anastomotic leak: • Fever • Tachycardia • Abdominal drain • Peritoneal drain Satisfying evidence: Documentation of abscess OR anastomotic leak	✔	✔	Documentation of peritonitis and clinical evidence of abscess or anastomotic leak without documentation of abscess or anastomotic leak	PERITONITIS There is documentation of peritonitis. Please document any associated diagnosis.	✔	✔	✔	✔
22000 Triggering evidence: Documentation of appendicitis AND (+/-) evidence of appendicitis: • Nausea and/or vomiting • Fever • Right lower quadrant pain • Rebound tenderness • Left shifted white blood cells Satisfying evidence: Documentation of the presence or absence of localized peritonitis OR documentation of the presence or absence of peritoneal abscess OR documentation of the presence or absence of generalized peritonitis OR documentation the presence or absence of ruptured appendix	✔	✔	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.	✔	✔		✔
410001 Triggering evidence: Documentation of small bowel removal OR transplant: • Small intestine excision • Transplantation of small intestine (+/-) clinical evidence of short bowel syndrome: • Including but not limited to: • Abdominal bloating • Stomach cramps • Abnormal weight loss • Unable to control flatus • Malabsorption syndrome (+/-) Evidence of CT abdomen Satisfying evidence: Documentation of short bowel syndrome: • Short bowel syndrome • Congenital short bowel syndrome	✔	✔	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 Triggering evidence: Documentation of gastrointestinal ulcer (+/-) Evidence of gastrointestinal ulcer: • Melena • Hematochezia • Hematemesis • Burning epigastric pain • Abdominal bloating Satisfying evidence: Documentation of acuity of gastrointestinal ulcer: • Acute • Chronic • Acute on chronic	✔	✔	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 Triggering evidence: Documentation of bowel ischemia OR necrosis: • Including but not limited to: • Anastomotic necrosis of small intestine • Anastomotic necrosis of large intestine • Excision of necrotic patch of small intestine • Hemorrhagic necrosis of intestine • Vascular insufficiency of intestine • Massive necrosis of intestine AND NO documentation of fat necrosis Satisfying evidence: Documentation of acuity of bowel ischemia or necrosis: • Including but not limited to: • Superior mesenteric artery syndrome • Insufficiency of mesenteric artery • Intestinal infarction • Any physician documented acuity of bowel ischemia or necrosis	✔	✔	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.	✔	✔		✔
51002162 Triggering evidence: Documentation of diverticulitis AND documentation of site of fluid collection in abdomen: • Any provider documented abdominal site of: • Encapsulated effusion • Loculated effusion • Effusion • Effusion of fluid and gas AND medication evidence of broad-spectrum antibiotics: • Including but not limited to: • Fluoroquinolones • Zosyn • Cefepime • Vancomycin • Meropenem (+/-) documentation of drain placement OR abdominal procedure: • Including but not limited to: • Insertion of peritoneal drain • Laparotomy • Large intestine excision • Operation on colon Satisfying evidence: Documentation of the presence OR absence of peritoneal abscess	✔	✔	Documentation of diverticulitis and evidence of abscess (+/- documentation of drain placement or abdominal procedure) without documentation of peritoneal abscess	DIVERTICULITIS There is evidence of fluid collection and broad-spectrum antibiotics with documentation of diverticulitis. Please document any associated diagnosis.	✔	✔		✔
51002284 Triggering evidence: Documentation of appendicitis AND documentation of site of fluid collection in abdomen: • Any provider documented abdominal site of: • Encapsulated effusion • Loculated effusion • Effusion • Effusion of fluid and gas AND medication evidence of broad-spectrum antibiotics: • Including but not limited to: • Fluoroquinolones • Zosyn • Cefepime • Vancomycin • Meropenem (+/-) documentation of drain placement OR abdominal procedure: • Including but not limited to: • Insertion of peritoneal drain • Laparotomy • Operation on appendix • Large intestine excision Satisfying evidence: Documentation of appendicitis with presence OR absence of abscess	✔	✔	Documentation of appendicitis and evidence of abscess (+/- documentation of drain placement or abdominal procedure) without documentation of the presence or absence of abscess	APPENDICITIS - B There is evidence of fluid collection, broad-spectrum antibiotics, and drain placement and/or abdominal surgery with documentation of appendicitis. Please document any associated diagnosis.	✔			✔
51002563 Triggering evidence: Clinical evidence of bowel ischemia OR necrosis: • Including but not limited to: • Intestinal necrosis • Dusky appearance of bowel • Non-viable bowel AND NO documentation of fat necrosis (+/-) documentation of bowel resection Satisfying evidence: Documentation of bowel ischemia OR necrosis: • Including but not limited to: • Superior mesenteric artery syndrome • Insufficiency of mesenteric artery • Intestinal infarction • Intestinal ischemia	✔	✔	Evidence of bowel ischemia or necrosis (+/- documentation of bowel resection) without documentation of bowel ischemia or necrosis	BOWEL CONDITION There is evidence of a bowel condition. Please document any associated diagnosis.	✔	✔		✔
51002682 Triggering evidence: Documentation of constipation OR fecal incontinence OR impaction AND radiology evidence of cauda equina syndrome OR cord compression OR megacolon AND documentation of a neurologic condition: • ALS • CVA • Parkinson's disease • Multiple Sclerosis • Spina bifida • Satisfying evidence: Documentation of the presence OR absence of neurogenic bowel	✔	✔	Provider documentation of constipation, fecal incontinence, or impaction and neurologic condition and radiology evidence of cauda equina syndrome or cord compression without documentation of the presence or absence of neurogenic bowel	GASTROINTESINAL AND OTHER DIGESTIVE DISORDERS There is documentation of constipation or fecal incontinence or impaction and a neurologic conditon and radiology evidence of cauda equina syndrome or cord compression or megacolon. Please document associated diagnosis.	✔
51002943 Triggering evidence: Documentation of gastroenteritis AND NOT documentation of viral gastroenteritis Satisfying evidence: Documentation of the etiology of gastroenteritis: • Any provider linked cause of the gastroenteritis	✔	✔	Documentation of non-viral gastroenteritis without documentation of the etiology of gastroenteritis	GASTROENTERITIS Please document the etiology of the non-viral gastroenteritis.
InflamDigestive-001 Triggering evidence: Documentation of peritonitis Satisfying evidence: Documentation of the etiology of peritonitis: • Including but not limited to: • Rupture of appendix • Rupture of instestine • Diverticulitis • Any provider linked cause of peritonitis • Idiopathic peritonitis • Multifactorial peritonitis	✔	✔	Documentation of peritonitis without documentation of the etiology of peritonitis	PERITONITIS ETIOLOGY Please document the etiology of peritonitis, if known.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
2003003 Triggering evidence: Documentation of CT of abdomen: • Computed tomography of abdomen • Computed tomography of abdomen with contrast • Computed tomography of abdomen and pelvis • Computed tomography of abdomen and pelvis with contrast • Cone beam computed tomography of abdomen AND MIN 3, evidence of ileus : • Bowel sounds absent • Nausea and vomiting • Abdominal bloating • Bowel distention • Swollen abdomen OR documentation of possible ileus Satisfying evidence: Documentation of ileus: • Postoperative ileus • Paralytic ileus • Intestinal obstruction due to decreased peristalsis	✔	✔	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 Triggering evidence: Documetation of small bowel obstruction (+/-) evidence of small bowel obstruction: • Abdominal pain • Swollen abdomen • Constipation • Vomiting • Electrolyte imbalance Satisfying evidence: Documentation of the etiology of the small bowel obstruction: • Any provider linked cause of the small bowel obstruction • Hernia • Diverticulitis • Adhesions • Idiopathic small bowel obstruction • Multifactorial small bowel obstruction AND documentation of the type of small bowel obstruction: • Partial • Complete	✔	✔	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.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
64001 Triggering evidence: Documentation of cancer of the small intestine: • Carcinoid tumor of small intestine • Malignant carcinoid tumor of duodenum • Malignant carcinoid tumor of jejunum • Malignant tumor of small intestine Satisfying evidence: Documentation of affected section of small intestine: • Any provider documented specific site of small intestine • Duodenum • Ileum • Jejunum • Ileocecal valve	✔	✔	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 Triggering evidence: Documentation of colon cancer: • Malignant neoplasm of colon • Malignant tumor of appendix • Malignant tumor of cecum Satisfying evidence: Documentation of affected section of the colon: • Entire colic flexure • Appendix structure • Transverse colon • Sigmoid colon • Cecum structure	✔	✔	Documentation of colon cancer without documentation of the affected section of the colon	COLON CANCER Please document the section of colon with cancer.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
2060001 Triggering evidence: Documentation of necrotizing enterocolitis (NEC) Satisfying evidence: Documentation of the stage of necrotizing enterocolitis (NEC)	✔	✔	Documentation of necrotizing enterocolitis without documentation of the stage of necrotizing enterocolitis	NECROTIZING ENTEROCOLITIS Please document the stage of necrotizing entercolitis (NEC).		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51001362^A Triggering evidence: Documentation of hepatic encephalopathy OR hepatic failure Satisfying evidence: Documentation of the presence OR absence of coma: • Coma • Hepatic coma	✔	✔	Documentation of hepatic encephalopathy or hepatic failure without documentation of the presence or absence of coma (age >18 years)	HEPATIC DISORDER Hepatic encephalopathy or hepatic failure have been documented. Please confirm the presence or absence of coma.		✔		✔
51001363^A Triggering evidence: Documentation of hepatic failure Satisfying evidence: Documentation of the acuity of hepatic failure: • Acute • Chronic • Acute on chronic • Subacute AND Documentation of the etiology of hepatic failure: • Any provider linked cause of hepatic failure • Idiopathic hepatic failure • Multifactorial hepatic failure	✔	✔	Documentation of hepatic failure without documentation of the acuity and etiology of hepatic failure (age >18 years)	HEPATIC DISORDER - B Hepatic failure has been documented. Please document the acuity and etiology of the hepatic failure.	✔	✔		✔
51002406^L Triggering evidence: INR >1.5 without anticoagulants OR INR >3 with anticoagulants AND lab evidence of hepatic failure: • ALT >165 • AST > 120 • Total bilirubin >1.5 • Platelets <150,000 (lab documents) (+/-) clincial evidence of hepatic failure: • Poisoning caused by drug AND/OR medication • Sepsis • Viral hepatitis • Malignant neoplasm • Severe hypotension Satisfying evidence: Documentation of hepatic failure with acuity: • Hepatic failure	✔	✔	Lab evidence of hepatic failure +/- clinical findings without documentation of hepatic failure with acuity	UNSPECIFIED CLINICAL CONDITION - G There is evidence of elevated INR and and hepatic laboratory abnormality. Please document any associated diagnosis.	✔	✔	✔	✔
57003 Triggering evidence: Documentation of hepatic encephalopathy Satisfying evidence: Documentation of etiology of hepatic encephalopathy: • Any provider linked cause of hepatic encephalopathy • Alcoholic hepatic failure • Cirrhosis of liver • Toxic liver disease • Idiopathic hepatic encephalopathy • Multifactorial hepatic encephalopathy	✔	✔	Documentation of hepatic encephalopathy without documentation of the etiology of hepatic encephalopathy	HEPATIC ENCEPHALOPATHY Please document etiology of hepatic encephalopathy.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
Cirrhosis-001 Triggering evidence: Documentation of cirrhosis of the liver Satisfying evidence: Documentation of the etiology of cirrhosis: • Including but not limited to: • Biliary cirrhosis • Cirrhosis - non-alcoholic • Infectious cirrhosis • Any provider linked cause of cirrhosis of liver • Idiopathic cirrhosis of liver • Multifactorial cirrhosis of liver AND documentation of the presence OR absence of ascites	✔	✔	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.				✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
50210^R Triggering evidence:* Documentation of portal hypertension in a radiology report (+/-) Evidence of portal hypertension: • Hepatic encephalopathy • Esophageal varices in cirrhosis of the liver • Abdominal varicosities • Gastroesophageal varices • Gastrointestinal hemorrhage		✔	Notification: Documentation of portal hypertension in a radiology report (+/- evidence of portal hypertension)

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
33001 Triggering evidence: Documentation of hepatitis Satisfying evidence: Documentation of the acuity of hepatitis: • Acute • Chronic	✔	✔	Documentation of hepatitis without documentation of acuity of hepatitis	HEPATITIS - ACUITY Please document the acuity of hepatitis.	✔	✔	✔
33002 Triggering evidence: Documentation of hepatitis: • Acute hepatitis • Chronic hepatitis • Cholangiohepatitis • Recurrent hepatitis • Toxic hepatitis Satisfying evidence: Documentation of hepatitis etiology or type: • Hepatitis A • Hepatitis B • Hepatitis C • Hepatitis E • Alcoholic hepatitis • Hepatitis of unknown etiology • Any physician linked cause of hepatitis • Idiopathic hepatitis • Multifactorial hepatitis	✔	✔	Documentation of hepatitis without documentation of etiology or type	HEPATITIS - ETIOLOGY Please document the etiology or type of hepatitis.	✔	✔	✔	✔
33003 Triggering evidence: Documentation of hepatitis : • Including but not limited to: • Toxic hepatitis • Acute non-infective hepatitis • Halothane hepatitis • Drug-induced hepatitis • Acute cholangiohepatitis AND evidence of hepatitis-inducing drug : • Including but not limited to: • Acetaminophen • Anabolic steroid • Methotrexate • Tetracycline • Vicodin AND NO documentation non-drug induced hepatitis Satisfying evidence: Documentation of the presence of absence of drug-induced hepatitis: • Drug-induced cholestatic hepatitis • Drug-induced chronic hepatitis • Drug-induced hepatitis • Toxic hepatitis	✔	✔	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 have a known adverse event of hepatitis. Please clarify whether these are causally related.		✔	✔
33004* Triggering evidence: Documentation of alcoholic hepatitis AND ascites		✔	Notification: Documentation of alcoholic hepatitis and ascites
33005* Triggering evidence: Documentation of hepatitis A OR B OR C with hepatic coma: • Hepatic coma due to viral hepatitis A • Hepatic coma due to viral hepatitis B • Hepatic coma due to viral hepatitis C • Hepatic coma due to chronic hepatitis B with delta agent		✔	Notification: Documentation of hepatitis A, B or C with hepatic coma
33006* Triggering evidence: Documentation of hepatitis B with delta agent: • Acute hepatitis B with delta agent (coinfection) with hepatic coma • Acute hepatitis B with delta-agent (coinfection) without hepatic coma • Hepatitis D superinfection of hepatitis B carrier • Chronic viral hepatitis B with delta-agent		✔	Notification: Documentation of hepatitis B with delta agent

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51000443 Triggering evidence: Documentation of malignant ascites Satisfying evidence: Documentation of primary malignancy site	✔	✔	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 Triggering evidence: Documentation of pancreatic cancer Satisfying evidence: Documentation of site in pancreas: • Any provider linked site within pancreas	✔	✔	Documentation of pancreatic cancer without documentation of affected site of the pancreas	PANCREATIC CANCER Please document the site of pancreatic cancer.	✔
63001 Triggering evidence: Documentation of cancer of biliary tract: • Carcinoid tumor of ampulla of Vater • Carcinoma in situ of ampulla of Vater • Cholangiocarcinoma • Malignant neoplasm of intrahepatic bile ducts • Malignant tumor of extrahepatic bile duct Satisfying evidence: Documentation of biliary cancer site (intrahepatic OR extrahepatic OR ampulla of Vater)	✔	✔	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* Triggering evidence: Documentation of cancer of gallbladder: • Local recurrence of malignant tumor of gallbladder • Malignant tumor of gallbladder • Primary malignant neoplasm of gallbladder • Carcinoma of gallbladder		✔	Notification: Documentation of cancer of the gallbladder

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
36001 Triggering evidence: Documentation of acute pancreatitis Satisfying evidence: Documentation of acute pancreatitis etiology: • Including but not limited to: • Acute necrotizing pancreatitis • Acute hemorrhagic pancreatitis • Acute pancreatitis due to infection • Familial acute pancreatitis • Viral acute pancreatitis • Any provider linked cause of pancreatitis • Idiopathic pancreatitis • Multifactorial pancreatitis	✔	✔	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 Triggering evidence: Documentation of acute pancreatitis (+/-) clinical evidence of ethanol abuse: • Alcohol dependence • Alcohol intoxication • Alcoholism • Alcohol intoxication delirium (+/-) lab evidence of ethanol abuse: • Ethanol >0 AND NO documentation of acute pancreatitis etiology as idiopathic, biliary, OR drug induced Satisfying evidence: Documentation of alcohol induced acute pancreatitis	✔	✔	Documentation of acute pancreatitis and (+/- clinical OR lab evidence of ethanol abuse) without documentation of alcohol induced acute pancreatitis	Evidence of alcohol abuse and acute pancreatitis were documented. Please clarify whether these are causally related.		✔
36003 Triggering evidence: Documentation of acute pancreatitis (+/-) evidence of pancreatitis-inducing drugs: • Including but not limited to: • Antidepressant • Antihypertensive • Corticosteroid • Valproate • Sulfasalazine AND NO documentation of acute pancreatitis etiology as idiopathic, biliary, OR alcohol-induced Satisfying evidence: Documentation of drug-induced acute pancreatitis	✔	✔	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 Triggering evidence: Documentation of pancreatitis Satisfying evidence: Documentation of acuity of pancreatitis: • Acute pancreatitis • Chronic pancreatitis • Subacute pancreatitis	✔	✔	Documentation of pancreatitis without documentation of the acuity of pancreatitis	PANCREATITIS - ACUITY Please document the acuity associated with pancreatitis (e.g., acute, subacute, acute on chronic, chronic), if known.	✔	✔	✔
50207 Triggering evidence: Documentation of pancreatitis (+/-) Clinical evidence of pancreatitis: • Epigastric pain • Abdominal pain • Nausea • Nausea and vomiting • Anorexia (+/- ) Chronic alcohol use: • Severe dependency (+/-) History of OR current biliary colic: • Calculus of gallbladder • Biliary colic Satisfying evidence: Documentation of acuity of pancreatitis: • Acute • Chronic • Acute on chronic • Subacute	✔	✔	Documentation of pancreatitis (+/- clinical evidence of pancreatitis) without documentation of the acuity of pancreatitis	PANCREATITIS Please document the acuity associated with pancreatitis (e.g., acute, subacute, acute on chronic, chronic), if known.	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
14004 Triggering evidence: Documentation of spondylosis: • Spondylosis • Degeneration of intervertebral disc • Radiculopathy • Osteoarthritis of facet joint • Calcification of disc • Osteoarthritis of facet joint Satisfying evidence: Documentation of spondylosis site : • Cervical • Thoracic • Lumbar • Lumbosacral	✔	✔	Documentation of spondylosis without documentation of the region/site of spondylosis	SPONDYLOSIS SITE Please document the spinal level of spondylosis.	✔
14005 Triggering evidence: Documentation of spondylosis Satisfying evidence: Documentation of presence or absence of myelopathy OR radiculopathy: • Cervical myelopathy • Degenerative myelopathy • Degenerative radiculopathy • Lumbar radiculopathy • Spinal cord disorder	✔	✔	Documentation of spondylosis without documentation of the presence or absence of myelopathy or radiculopathy	SPONDYLOSIS Please document any other diagnosis(es) associated with spondylosis.	✔
14017 Triggering evidence: Documentation of arthritis of knee (+/-) documentation of radiology studies: • Radiography • Computed tomography • Magnetic resonance imaging • Stress X-ray Satisfying evidence: Documentation type of arthritis of knee: • Traumatic arthropathy • Infective arthritis • Osteoarthritis • Rheumatoid arthritis AND documentation of knee laterality : • Right • Left • Bilateral	✔	✔	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.	✔		✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
14012 Triggering evidence: Documentation of meniscus tear of knee Diagnostic imaging documentation : • Magnetic resonance imaging of knee joint • Computed tomography of knee joint • Radiography of knee Satisfying evidence: Documentation of type of meniscus tear : • Bucket handle meniscus tear • Complex meniscus tear • Flap meniscus tear • Horizontal meniscus tear • Longitudinal meniscus tear AND knee laterality : • Right • Left • Bilateral AND meniscus laterality : • Lateral meniscus of knee • Medial meniscus of knee	✔	✔	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 knee laterality, type, and laterality of the meniscus tear.				✔
14014 Triggering evidence: Documentation of rotator cuff injury Documentation of radiology studies: • Radiography • Computed tomography • Magnetic resonance imaging • Stress X-ray Satisfying evidence: Dcoumentation of type of injury: • Including but not limited to: • Complete rupture • Partial tickness tear • Tendinitis • Traumatic rupture • Strain of rotator cuff AND Documentation of rotator cufff tendon/tendons : • Infraspinatus • Teres minor • Supraspinatus • Subscapularis AND Documentation of laterality: • Right • Left • Bilateral	✔	✔	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.	✔			✔
50201 Triggering evidence: Documentation of osteomyelitis (+/-) evidence of osteomyelitis: • Bone pain • Erythema of skin • Fatigue • Fever with chills • Tenderness of joint Satisfying evidence: Documentation of acuity of osteomyelitis: • Acute • Acute on chronic • Chronic	✔	✔	Documentation of osteomyelitis (+/- clinical evidence of osteomyelitis) without documentation of acuity of osteomyelitis	OSTEOMYELITIS Please document the acuity of osteomyelitis.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
14000 Triggering evidence: Documentation of fracture: • Open fracture • Closed fracture • Displaced fracture • Non-displaced fracture • Avulsion fracture AND (+/-) clinical evidence of stress fracture: • Backache • Bone pain • Numbness • Tenderness and swelling • Numbness AND NO documentation of pathological fracture OR documentation of malignancy OR medication evidence of osteoporosis OR documentation of bone disease OR documentation of major trauma Satisfying evidence: Documentation of stress fracture	✔	✔	Documentation of a fracture (+/- clinical evidence of a stress fracture) without documentation of stress fracture	FRACTURE Please document the type of fracture.	✔			✔
14001 Triggering evidence: Documentation of fracture : • Open fracture • Closed fracture • Displaced fracture • Non-displaced fracture • Avulsion fracture OR documentation of nontraumatic fracture: • Compression fracture • Stress fracture • Insufficiency fracture • Chronic fracture AND medication evidence of osteoporosis: • Bisphosphonates • Denosumab • Calcium supplements OR documentation of clinical evidence of osteoporosis: • Bone density below reference range • Osteoporosis • Osteopenia AND NO documentation of major trauma : • Accidental injury • Motor vehicle accident • Slipping or falling • Assault Satisfying evidence: Documentation of a pathological fracture: • Stress fracture • Osteoporotic fracture • Chronic fracture • Fragility fracture • Insifficiency fracture	✔	✔	Documentation of a nontraumatic fracture and evidence or documentation 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 Triggering evidence: Documentation of fracture: • Open fracture • Closed fracture • Displaced fracture • Non-displaced fracture • Avulsion fracture AND documentation of malignancy: • Carcinoma • Sarcoma • Lymphoma • Medulloblastoma • Glioma • Craniopharyngioma AND NO evidence of major trauma: • Accidental injury • Motor vehicle accident • Slipping or falling • Assault Satisfying evidence: Documentation of pathological fracture: • Pathological fracture • Insufficiency frcature • Chronic fracture • Fragility frcature	✔	✔	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 Triggering evidence: Documentation of a bone disease : • Metabolic bone disease • Osteitis • Bone cyst • Osteomalacia • Osteomyelitis AND documentation of fracture: • Open fracture • Closed fracture • Displaced fracture • Non-displaced fracture • Avulsion fracture OR documentation of nontraumatic fracture: • Collapse fracture • Chronic fracture • Compression fracture • Stress fracture AND NO documentation of major trauma: • Accidental injury • Motor vehicle accident • Slipping or falling • Assault Satisfying evidence: Documentation of pathological fracture: • Chronic fracture • Fragility fracture • Pathological fracture • Insufficiency fracture	✔	✔	Documentation of a bone disease and a nontraumatic fracture without documentation of pathologic fracture	FRACTURE - B There is documentation of fracture and bone disease with no evidence of major trauma. Please document the type of fracture.	✔		✔	✔
14009 Triggering evidence: Documentation of fracture Satisfying evidence: Documentation of type fracture: • Traumatic fracture • Stress fracture • Pathological fracture AND documentation of alignment : • Displaced • Non-displaced • Angulated • Dislocated • Rotated AND documentation of course: • Stable fracture • Unstable fracture	✔	✔	Documentation of fracture without documentation of the alignment, stability, and type of fracture	FRACTURE TYPE Please document the type, alignment, and stability of fracture, if known.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
14019^A Triggering evidence: Lab evidence of creatinine kinase >1500 AND clinical evidence of rhabdomyolysis: • Crushing injury • Excessive exercise • Found down • Traumatic injury • Fall Satisfying evidence: Documentation of rhabdomyolysis: • Exertional rhabdomyolysis • Secondary rhabdomyolysis • Muscle crush syndrome • Non-traumatic rhabdomyolysis • Haff Syndrome	✔	✔	Clinical and lab evidence of rhabdomyolysis without documentation of rhabdomyolysis (age: > 18 years)	HIGH CK AND TRAUMA There is evidence of creatine kinase >1500 U/L and injury. Please document any associated diagnosis.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
62001 Triggering evidence: Documentation of breast cancer: • Ductal carcinoma in situ (DCIS) • Infiltrating ductal carcinoma • Infiltrating lobular carcinoma • Mixed ductal/lobular carcinoma Satisfying evidence: Documentation of site in breast: • Any provider documented breast site AND laterality of affected breast: • Right • Left • Bilateral	✔	✔	Documentation of breast cancer without documentation of site and laterality of affected breast	BREAST CANCER Please document the site and laterality of breast cancer.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
20007^S Triggering evidence: Documentation of ulcer: • Ischemic ulcer • Non-pressure ulcer • Ulcer • Stasis ulcer • Neurogenic ulcer AND Documentation of diabetes OR MIN 2 of lab or clinical evidence of diabetes: • Hemoglobin A1c greater than 7 • Insulin usage • Oral hypoglycemic usage Satisfying evidence: Documentation of diabetic ulcer OR Documentation of negated diabetic ulcer	✔	✔	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 evidence of an endocrine condition. Please document whether these are causally related.
20009^S Triggering evidence:* Documentation of a pressure ulcer, pressure injury, pressure wound or pressure sore	✔	✔	Notification: Documentation of a pressure ulcer, injury, wound, or sore	SKIN CONDITION - B There is documentation of a pressure ulcer/injury/wound/sore.
20014^S Triggering evidence: Documentation of pressure ulcer Satisfying evidence: Documentation of pressure ulcer present on admission status OR documentation of the presence of pressure ulcer on the history and physical document	✔	✔	Documentation of a pressure ulcer without documentation of present on admission status	PRESSURE ULCER POA Please document whether pressure ulcer was present on admission.
20016^S Triggering evidence: Documentation of skin ulcer OR skin lesion OR wound: • Diabetic ulcer • Ischemic ulcer • Traumatic ulcer • Plaster ulcer • Pressure injury of deep tissue • Skin ulcer Satisfying evidence: Documentation of the type of skin ulcer: • Pressure ulcer • Non pressure ulcer • First degree burn • Blistering eruption	✔	✔	Documentation of a skin ulcer without documentation of the type of skin ulcer	SKIN ULCER TYPE Please document the type of skin ulcer.	✔	✔
20019^S Triggering evidence: Documentation of non-pressure ulcer: • Diabetic ulcer • Ischemic ulcer • Traumatic ulcer • Stasis ulcer • Neuropathic ulcer Satisfying evidence: Documentation of the type of non-pressure ulcer: • Including, but not limited to: • Acute tuberculous ulcer • Hypertensive leg ulcer • Infective varicose ulcer • Foot ulcer due to diabetes mellitus AND documentation of the site of the non-pressure ulcer AND documentation of the number of non-pressure ulcer(s) AND documentation of the laterality of non-pressure ulcer: • Laterality if applicable AND documentation of non-pressure ulcer present on admission status OR documentation of the presence of non-pressure ulcer on the history and physical document	✔	✔	Documentation of a non-pressure ulcer without documentation of the type, site, number, laterality, and present on admission status of the non-pressure ulcer	NON-PRESSURE ULCER Please document the type, site, present on admission status, number, and laterality of the non-pressure ulcer.	✔
20024^S Triggering evidence: Documentation of pressure ulcer: • Deep pressure ulcer • Plaster ulcer • Pressure injury of deep tissue • Gangrenous pressure ulcer • Non-stageable pressure ulcer Satisfying evidence: Documentation of the site, stage, laterality AND number of pressure ulcer(s) AND documentation of the presence of pressure ulcer on the history and physical document OR documentation of negated pressure ulcer on the history and physical document OR documentation of the pressure ulcer present on admission status	✔	✔	Documentation of a pressure ulcer without documentation of the laterality, number, site, stage, and present on admission status of the pressure ulcer	PRESSURE ULCER Please document the site, stage, laterality, number and POA of a pressure ulcer.
51001682^S Triggering evidence: Documentation of a pressure injury: • Including but not limited to: • Pressure injury • Gangrenous pressure ulcer • Pressure injury of deep tissue Satisfying evidence: Documentation of site of pressure injury: • Any physician documented site of pressure injury	✔	✔	Documentation of a pressure injury without documentation of the site of the pressure injury	PRESSURE INJURY SITE Please document the site of the pressure injury.		✔	✔
SkinLesions-001^S Triggering evidence: Documentation of ulcer: • Stasis ulcer • Ulcer • Ischemic ulcer • Neuropathic ulcer • Non-pressure ulcer AND Documentation of diabetes Satisfying evidence: Documentation of diabetic ulcer OR Documentation of negated diabetic ulcer	✔	✔	Documentation of a ulcer and diabetes without documentation of the relationship between the ulcer and diabetes	DIABETIC ULCER There is a documentation of ulcer and diabetes, please document the relation if known.
SkinLesions-002^S Triggering evidence: Documentation of a pressure ulcer: • Plaster ulcer • Deep pressure ulcer • Gangrenous pressure ulcer • Pressure injury of deep tissue Satisfying evidence: Documentation of the site of the pressure ulcer AND documentation of pressure ulcer present on admission status OR documentation of the presence of a pressure ulcer on the history and physical document	✔	✔	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.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
19000^S Triggering evidence: Documentation of debridement OR evidence of debridement: • Curette • Scalpel • Sharp dissection AND (+/-) documentation of depth: • Subcutaneous tissue • Eschar • Granulation tissue • Fascia • Muscle OR documentation of measurement: • Inch • Centimeter • Millimeter • Square inch OR documentation of wound: • Burn • Pressure Ulcer • Gangrene • Surgical wound • Laceration AND NO documentation of false positive cases : • Calcium debridement • Arthrotomy • Arthroscopy • Cataract • Meniscectomy of knee Satisfying evidence: Documentation of excisional debridement	✔	✔	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^S Triggering evidence: Documentation of excisional debridement AND (+/-) documentation of wound: • Burn • Chronic ulcer • Gangrene • Necrosis • Ischemic ulcer OR documentation of depth: • Adipose tissue • Bleeding tissue • Entire dermis • Full thickness • Eschar OR documentation of measurement: • Inch • Centimeter • Millimeter • Square inch • Square millimeter AND NO false positive debridement cases : • Arthroscopy • Cataract • Endoscopic procedure • Operation on ligament • Repair of joint OR documentation of razor or hair shaving Satisfying evidence: Evidence of excisional debridement: • Knife • Scalpel • Sharp dissection • Curette • Scissors OR documentation of sharp debridement: • Sharp debridement • Shave debridement • Surgical debridement	✔	✔	Documentation of excisional debridement (+/- evidence of wound characteristics or debridement level) without documentation of sharp debridement or instrument evidence of excisional debridement	EXCISIONAL DEBRIDEMENT Please include all the clinical indicators supporting the diagnosis of excisional debridement.
19002^S Triggering evidence:* Documentation of debridement: • Debridement • Excisional debridement • Non-excisional debridement • Sharp debridement AND NO false positive debridement cases: • Arthroscopy • Cataract • Endoscopic procedure • Operation on ligament • Repair of joint	✔	✔	Notification: Documentation of debridement	DEBRIDEMENT - C Debridement was documented. Please refer to the wound debridement form in the assessment section to document all necessary items for this debridement.
19003^S Triggering evidence: Documentation of debridement (+/-) evidence of excisional debridement: • Sharp instrument • Knife • Forceps • Sharp dissection • Curette Satisfying evidence: Documentation of excisional debridement OR documentation of non-excisional debridement	✔	✔	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^S Triggering evidence: Documentation of debridement AND (+/-) evidence of excisional debridement: • Knife, device • Scalpel, device • Scissors, device • Sharp dissection • Curette Satisfying evidence: Documentation of debridement depth: • Adipose tissue • Bleeding tissue • Entire dermis • Full thickness • Eschar	✔	✔	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^S Triggering evidence: Documentation of debridement : • Debridement • Excisional debridement of burn • Debridement of soft tissue • Debridement of infection skin • Debridement of muscle (+/-) Evidence of excisional debridement: • Scalpel, device • Scissors, device • Sharp dissection • Curette • Forceps Satisfying evidence: Documentation of depth: • Skin • Subcutaneous tissue • Fascia • Muscle • Tendon bone • Bursa • Joint AND Documentation of excisional OR nonexcisional debridement	✔	✔	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 and level/depth of debridement.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
20010 Triggering evidence: Documentation of incision and drainage Satisfying evidence: Documentation of level/depth of tissue involved: • Connective tissue structure • Mucous membrane structure • Muscle tissue structure • Soft tissue structure • Structure of epithelium	✔	✔	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.
2003002 Triggering evidence: Documentation of wound : • Deep wound • Incised wound • Open wound • Surgical wound AND MIN,3 evidence of a wound infection: • Temperature > 101 F or 38.3 C • Erythema • Exudate • Purulent discharge • Wound pain Satisfying evidence: Documentation of wound infection : • Cellulitis • Surgical site infection • Wound abscess • Wound cellulitis	✔	✔	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 documentation of a wound and clinical evidence of elevated temperature and/or wound infection. Please document any associated condition.	✔			✔
51002342 Triggering evidence: Documentation of lupus erythematosus Satisfying evidence: Documentation of the type of lupus erythematosus: • Including but not limited to: • Acute systemic lupus erythematosus • Cutaneous lupus erythematosus • Drug-induced lupus erythematosus • Systemic lupus erythematosis • Neonatal lupus erythematosis	✔	✔	Documentation of lupus erythematosus without documentation of the type of lupus erythematosus	LUPUS Please document the type of lupus.	✔		✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
20005^S Triggering evidence:* Documentation of skin lesion, ulcer, wound or burn : • Abscess of skin • Burn • Pressure ulcer • Non-pressure ulcer • Diabetic foot ulcer AND NO documentation of squamous cell carcinoma OR documentation of squamous cell carcinoma AND NO non-skin ulcer site: • Abdominal esophagus structure • Brain structure • Cecum structure • Duodenal structure • Entire pupil	✔	✔	Notification: 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 document all of the attributes of each skin lesion, ulcer, wound, or burn.
20006^S Triggering evidence: Documentation of skin lesion OR skin ulcer OR wound: • Diabetic ulcer • Ischemic ulcer • Traumatic ulcer • Plaster ulcer • Pressure injury of deep tissue • Skin ulcer • Skin lesion • Wound Satisfying evidence: Documentation of skin lesion OR skin ulcer OR wound present on admission status OR Documentation of the presence of skin lesion OR skin ulcer OR wound on the history and physical document	✔	✔	Documentation of a skin lesion, skin ulcer, or wound without documentation of present on admission status	SKIN LESION POA Please document if the skin lesion was present on admission.
20017^S Triggering evidence: Documentation of a skin lesion OR ulcer OR wound: • Diabetic ulcer • Pressure ulcer • Cellulitis • Abscess of skin • Pressure injury of deep tissue • Skin lesion Satisfying evidence: Documentation of type of skin lesion OR ulcer OR wound: • Pressure ulcer • Non-pressure ulcer • Blistering eruption • Laceration • Puncture AND documentation of a skin lesion OR ulcer OR wound present on admission status OR documentation of the presence of a skin lesion OR ulcer OR wound on the history and physical document	✔	✔	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^S Triggering evidence: Documentation of a burn, skin lesion, ulcer OR wound: • Diabetic ulcer • Ischemic ulcer • Traumatic ulcer • Plaster ulcer • Pressure injury of deep tissue • Skin ulcer • Skin lesion • Wound Satisfying evidence: Documentation of the laterality of burn, skin lesion, ulcer OR wound AND documentation of the site of burn, skin lesion, ulcer OR wound AND documentation of the number of burn, skin lesion, ulcer OR wound AND documentation of burn, skin lesion, ulcer OR wound present on admission status OR documentation of the presence of a burn, skin lesion, ulcer OR wound on the history and physical document	✔	✔	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 laterality, number, site, and POA status of the documented skin lesion or wound .
20023^S Triggering evidence: Documentation of a skin lesion, pressure ulcer, primary ulcer OR wound : • Diabetic ulcer • Ischemic ulcer • Traumatic ulcer • Plaster ulcer • Pressure injury of deep tissue • Skin ulcer • Skin lesion • Wound Satisfying evidence: Documentation of the pathogenesis OR episodicity of the skin lesion, pressure ulcer, primary ulcer OR wound	✔	✔	Documentation of a skin lesion, ulcer, or wound without documentation of the episodicity or pathogenesis of the lesion, ulcer, or wound	SKIN CONDITION - STATE There is documentation of a skin lesion, pressure ulcer, or wound, please verify the state.
20025^S Triggering evidence: Documentation of a skin lesion, pressure ulcer, primary ulcer OR wound: • Including, but not limited to: • Diabetic ulcer • Abscess of skin • Traumatic ulcer • Pressure ulcer • Pressure injury of deep tissue • Puncture wound • Skin lesion Satisfying evidence: Documentation of the size or measurement of the skin lesion, pressure ulcer, primary ulcer OR wound	✔	✔	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.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
26000^L Triggering evidence: Lab evidence of respiratory alkalosis: • [requires all lab evidence from the same lab document] • pCO2 arterial < than 35 mmHg • pH arterial > than 7.45 (+/-) documentation of the cause of respiratory alkalosis : • Acute asthma • Acute exacerbation of chronic obstructive pulmonary disease • Hyperventilation syndrome • Pneumonia • Pulmonary edema • Pulmonary embolism • Pain crisis (+/- ) clinical evidence of respiratory alkalosis: • Dyspnea • Gasping for breath • Increased breathlessness • Tachypnea • Anxiety Satisfying evidence: Documentation of respiratory alkalosis : • Respiratory alkalosis • Respiratory alkalosis and metabolic acidosis • Respiratory alkalosis and metabolic alkalosis	✔	✔	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^L Triggering evidence: Lab evidence of respiratory acidosis: • [requires all lab evidence from the same lab document] • pCO2 arterial > than 45 mmHg • pH arterial < than 7.35 (+/-) clinical evidence of respiratory acidosis : • Dyspnea • Hypoventilation • Lethargy • Shortness of breath • Delirium (+/-) documentation of the etiology of respiratory acidosis: • Acute cerebrovascular accident • Chronic obstructive pulmonary disease • Obesity with alveolar hypoventilation • Flail chest • Myasthenia gravis • Obstructive sleep apnea syndrome Satisfying evidence: Documentation of respiratory acidosis: • Acute respiratory acidosis • Compensated respiratory acidosis • Respiratory acidosis and metabolic acidosis • Respiratory acidosis and metabolic alkalosis	✔	✔	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^L Triggering evidence: Lab evidence of metabolic alkalosis: • [requires all lab evidence from the same lab document] • HCO3 arterial > than 27 mEq/L • pH arterial > than 7.45 (+/-) documentation of the etiology of metabolic alkalosis: • Diarrhea • Diuretic • Vomiting • Gastric lavage • Barret syndrome (+/-) clinical evidence of metabolic alkalosis: • Coma • Restlessness • Muscle weakness • Disoriented • Fatigue • Feeling agitated Satisfying evidence: Documentation of metabolic alkalosis: • Metabolic alkalosis • Metabolic acidosis and metabolic alkalosis • Respiratory acidosis and metabolic alkalosis • Respiratory alkalosis and metabolic alkalosis	✔	✔	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^L Triggering evidence: Lab evidence of metabolic acidosis: • [requires all lab evidence from the same lab document] • pH arterial < than 7.35 • HCO3 arterial < than 22 mEq/L (+/-) documentation of the etiology of metabolic acidosis: • Lactic acidosis • Diarrhea • Chronic kidney disease • Ketoacidosis • Toxic effect of methylene alcohol (+/-) clinical evidence of metabolic acidosis : • Ketotic breath • Lethargy • Coma • Tachypnea • Hypotension Satisfying evidence: Documentation of metabolic acidosis: • Metabolic acidosis • Metabolic acidosis and metabolic alkalosis • Respiratory acidosis and metabolic alkalosis • Respiratory alkalosis and metabolic acidosis • Hyperosmolar hyperglycemic state	✔	✔	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.	✔	✔		✔
51001603 Triggering evidence: Lab evidence of acidosis: • Lactate > than 4 mmo/L • pH arterial < than 7.35 • pCO2 arterial > than 45 mmHg • HCO3 arterial < 22 mEq/L (+/-) clinical evidence of respiratory OR metabolic acidosis : • Dyspnea • Hypoventilation • Lethargy • Shortness of breath • Delirium • Ketotic breath • Lethargy • Coma • Tachypnea • Hypotension Satisfying evidence: Documentation of acidosis: • Including but not limited to: • Acidosis • Metabolic acidosis and metabolic alkalosis • Respiratory alkalosis and metabolic acidosis • Acidemia • Ketoacidosis	✔	✔	Lab evidence of acidosis (+/- clinical evidence of respiratory or metabolic acidosis) without documentation of acidosis	ACID BASE DISORDER There is evidence of an acid-base disorder. Please document any associated conditions.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
40501 Triggering evidence: Documentation of cystic fibrosis: • Cystic fibrosis • Arthropathy associated with cystic fibrosis • Diabetes mellitus due to cystic fibrosis • Perinatal jaundice due to mucoviscidosis Satisfying evidence: Documentation of a manifestation of cystic fibrosis: • Including but not limited to: • Chronic obstructive pulmonary disease • Cor pulmonale • Failure to thrive • Hydrocele • Pneumonia	✔	✔	Documentation of cystic fibrosis without documentation of a manifestation of cystic fibrosis	CYSTIC FIBROSIS Please document any manifestations of cystic fibrosis.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
21000* Triggering evidence: MIN,2 Documentation of diabetes mellitus: • Including but not limited to: • Diabetes mellitus • Gestational diabetes • Brittle diabetes • Diabetic foot ulcer AND clinical evidence of primary complications: • Coma • Hypernatremia • Hyperosmolarity • Ketoacidosis • Ketotic coma due to DM OR lab evidence of primary complications: • pH < 7.35 • Hgb A1c > 7 • Na > 145 meq/L • Serum Ketones > 1.0 mg/dL or 0.1 mmol/L • Glucose > 400 mg/dL or 22.2 mmol/L • Osmolality > 320 OR documentation of uncontrolled diabetes: • DM uncontrolled • Diabetic- poor control • Type I DM uncontrolled • Type II DM uncontrolled (+/-) secondary complications of diabetes: • CKD • Ulcers • Arthropathy • Neuropathy • Retinopathy		✔	Notification: Documentation of diabetes and lab or clinical evidence of a primary complication of diabetes (+/- documentation of a secondary complication of diabetes)
21002 Triggering evidence: MIN,2 Documentation of diabetes mellitus: • Diabetes mellitus • Gestational diabetes • Brittle diabetes • Diabetic foot ulcer Satisfying evidence: Documentation of the type of diabetes mellitus: • Diabetes mellitus with type • Gestational diabetes • Pre-existing diabetes with type • Insulin resistant diabetes with type	✔	✔	Documentation of diabetes without documentation of the type of diabetes	DIABETES MELLITUS Please document the type of diabetes mellitus.	✔	✔		✔
21003* Triggering evidence: Documentation of insulin: • Insulin Lispro • Insulin regular • Insulin Glargine • Humalog • Humulin OR Documentation of sliding scale insulin		✔	Notification: Documentation of insulin therapy
21004* Triggering evidence: Documentation of insulin pump (+/-) documentation of insulin pump malfunction: • Equipment error/ failure • Equipment malfunction • Medication dose too high • Medication dose too low • Pump malfunction		✔	Notification: Documentation of an insulin pump (+/- evidence of insulin pump malfunction)		✔			✔
21005* Triggering evidence: Documentation of diabetes type 1: • Including but not limited to: • Brittle type I diabetes mellitus • Diabetes mellitus type I • Type I diabetes mellitus uncontrolled • Type I diabetes mellitus well controlled AND documentation of diabetes type 2: • Including but not limited to: • Brittle type II diabetes mellitus • Diabetes mellitus type II • Type II diabetes mellitus uncontrolled • Type II diabetes mellitus well controlled NOT documentation of latent autoimmune diabetes mellitus in adult		✔	Notification: Documentation of both diabetes type 1 and type 2
21006 Triggering evidence: MIN,2 Documentation of diabetes: • Diabetes mellitus • Gestational diabetes • Brittle diabetes • Diabetic foot ulcer AND documentation of diabetic complication: • CKD • Ulcers • Arthropathy • Neuropathy • Retinopathy Satisfying evidence: Documentation of complication due to diabetes: • Any physician linked complication to diabetes • Autonomic neuropathy • Diabetic cardiomyopathy • Disorder of kidney due to DM • PVD due to DM • Diabetic skin ulcer	✔	✔	Documentation of diabetes and a complication of diabetes without documentation of the relationship between diabetes and the complication	DIABETES - D Diabetes is documented. Please document any causally related complication of the diabetes.	✔	✔		✔
21007* Triggering evidence: MIN,2 Documentation of diabetes: • Diabetes mellitus • Gestational diabetes • Brittle diabetes • Diabetic foot ulcer AND documentation of diabetic complication: • CKD • Ulcers • Arthropathy • Neuropathy • Retinopathy		✔	Notification: Documentation of diabetes and a complication of diabetes
21009 Triggering evidence: Documentation of uncontrolled diabetes: • DM uncontrolled • Diabetic- poor control • Type I DM uncontrolled • Type II DM uncontrolled Satisfying evidence: Documentation of hyperglycemia : • Hyperglycemia • Hyperglycemia due to DM • Impaired glucose tolerance in pregnancy • Neonatal hyperglycemia due to insulin deficiency • Transient neonatal hyperglycemia OR documentation of hypoglycemia: • Hypoglycemia • Hypoglycemic syndrome • Insulin coma • Neonatal hypoglycemia	✔	✔	Documentation of poorly controlled or uncontrolled diabetes without documentation of hyperglycemia or hypoglycemia	UNCONTROLLED DIABETES There is documentation of uncontrolled diabetes. Please document any associated diagnosis.		✔
43002 Triggering evidence: Documentation of DKA OR lab evidence of DKA: • Glucose >250 mg/dL or 13.9 mmol/L • pH arterial <= 7.3 • Beta hydroxybutyrate >= 1.0 mmol/L • Urine ketones positive • Serum ketones positive AND documentation of coma OR clinical evidence of coma: • ET Tube • Intubation • Metabolic encephalopathy Satisfying evidence: Documentation of DKA AND coma	✔	✔	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 any diagnoses and their relationship, if applicable.	✔	✔		✔
43003 Triggering evidence: Evidence of diabetic ketoacidosis: • Glucose >250 mg/dL or 13.9 mmol/L • pH arterial <=7.3 • Beta hydroxybutyrate >= 1.0 mmol/L • Urine ketones positive • Serum ketones positive Satisfying evidence: Documentation of diabetic ketoacidosis: • Diabetic ketoacidosis • Ketotic coma	✔	✔	Lab evidence of diabetic ketoacidosis without documentation of diabetic ketoacidosis	ABNORMAL LABS There is evidence of an elevated glucose, low pH, and evidence of serum or urine ketones. Please document any associated diagnosis.	✔	✔		✔
43007 Triggering evidence: MIN,2 documentation of diabetes: • Including but not limited to: • Diabetes mellitus • Gestational diabetes • Brittle diabetes • Diabetic foot ulcer Satisfying evidence: Documentation of diabetes controlled OR uncontrolled (+/-) lab evidence of diabetic complications/uncontrolled treatment: • pH < 7.35 • Hgb A1c > 7 • Na > 145 meq/L • Serum Ketones > 1.0 mg/dL or 0.1 mmol/L • Glucose > 400 mg/dL or 22.2 mmol/L • Osmolality > 320 (+/-) clinical evidence of diabetic complications/uncontrolled treatment: • Including but not limited to: • Coma • Hyperosmolarity • Ketoacidosis • CKD • Ulcers • Arthropathy • Neuropathy	✔	✔	Documentation of diabetes without documentation of whether diabetes is controlled or uncontrolled	DIABETES - C There is documentation of diabetes, please document the status.		✔
51001702 Triggering evidence: Documentation of diabetes AND MIN,2 evidence of glucose >140 mg/dL Satisfying evidence: Documentation of hyperglycemia: • Hyperglycemia • Hyperglycemia due to diabetes mellitus • Impaired glucose tolerance in pregnancy • Neonatal hyperglycemia due to insulin deficiency • Transient neonatal hyperglycemia	✔	✔	Documentation of diabetes mellitus and lab evidence of elevated glucose without documentation of hyperglycemia	DIABETES - B There is documentation of diabetes and evidence of elevated glucose levels. Please document any associated diagnosis
Diabetes-001 Triggering evidence: Lab evidence of diabetes mellitus: • Glucose > 180 mg/dL • Hemoglobin A1C > 6.5 Satisfying evidence: Documentation of the type of diabetes mellitus: • Diabetes mellitus with type • Gestational diabetes • Pre-existing diabetes with type • Insulin resistant diabetes with type	✔	✔	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 Triggering evidence: Documentation of glucose >200 OR documentation of hyperglycemia: • Latrogenic neonatal hyperglycemia • Non-diabetic hyperglycemia • Steroid-induced hyperglycemia • Hyperglycemia • Satisfying evidence: Documentation of the etiology of hypergylcemia: • Any provider linked cause of hyperglycemia • Idiopathic hyperglycemia • Multifactorial hyperglycemia • Hyperglycemia not caused by DM • Hyperglycemia due to DM • Drug-induced hyperglycemia	✔	✔	Documentation and lab evidence of hyperglycemia without documentation of the etiology of hyperglycemia	ELEVATED GLUCOSE ETIOLOGY There is documentation or evidence of elevated glucose >200. Please document any associated diagnosis and etiology.	✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
24001 Triggering evidence: MIN,2 Lab evidence of hyponatremia: • Sodium (Na) <= 130 (age < 19 years) • Sodium (Na) <= 130 (age >= 19 years) (+/-) Medication evidence of treatment for hyponatremia: • Sodium chloride • Vaprisol • Conivaptan • Tolvaptan Satisfying evidence: Documentation of hyponatremia OR Documentation of low sodium as not clinically significant	✔	✔	Lab evidence of hyponatremia (+/- medication evidence of treatment for hyponatremia) without documentation of hyponatremia	LOW SODIUM There is evidence of low sodium. Please document any associated diagnosis.	✔
24002 Triggering evidence: MIN, 2 Lab evidence of hypernatremia : • Sodium level greater than 145 (+/-) Medication evidence of treatment for hypernatremia: • Including but not limited to: • IV sodium chloride 0.45% and glucose 5% • Lactated Ringer's Satisfying evidence: Documentation of hypernatremia OR Documentation of high sodium not clinically significant	✔	✔	Lab evidence of hypernatremia (+/- medication evidence of treatment for hypernatremia) without documentation of hypernatremia	HIGH SODIUM There is evidence of high sodium. Please document any associated diagnosis.	✔
24003 Triggering evidence: MIN,2 Lab evidence of hypokalemia: • Potassium <= 2.5 (age < 19) • Potassium <= 2.8 (age >= 19) (+/-) Medication evidence of treatment for hypokalemia: • Citric acid • Dyrenium • Effer-K • Potassium • Potassium gluconate Satisfying evidence: Documentation of hypokalemia	✔	✔	Lab evidence of hypokalemia (+/- medication evidence of treatment for hypokalemia) without documentation of hypokalemia	LOW POTASSIUM There is evidence of low potassium. Please document any associated diagnosis.
24004 Triggering evidence: MIN,2 Lab evidence of hyperkalemia: • Potassium >= 5.5 (age < 19) • Potassium >= 6.2 (age >= 19) (+/-) medication evidence of treatment for hyperkalemia: • Calcium chloride • Insulin, regular, human • Calcibind • Lokelma Satisfying evidence: Documentation of hyperkalemia	✔	✔	Lab evidence of hyperkalemia (+/- medication evidence of treatment for hyperkalemia) without documentation of hyperkalemia	HIGH POTASSIUM There is evidence of high potassium. Please document any associated diagnosis.
24005 Triggering evidence: MIN,2 Lab evidence of hypocalcemia: • Calcium <= 6.0 (+/-) Medication evidence of treatment for hypocalcemia: • Calcium gluconate • Calcium carbonate • Calcium chloride Satisfying evidence: Documentation of hypocalcemia	✔	✔	Lab evidence of hypocalcemia (+/- medication evidence of treatment for hypocalcemia) without documentation of hypocalcemia	LOW CALCIUM There is evidence of low calcium. Please document any associated diagnosis.	✔
24006 Triggering evidence: MIN,2 Lab evidence of hypercalcemia : • Calcium >= 13 AND (+/-) medication evidence of treatment for hypercalcemia: • Calcitonin • Denosumab • Zoledronic acid • Alendronate Satisfying evidence: Documentation of hypercalcemia	✔	✔	Lab evidence of hypercalcemia (+/- medication evidence of treatment for hypercalcemia) without documentation of hypercalcemia	HIGH CALCIUM There is evidence of high calcium. Please document any associated diagnosis.
24007 Triggering evidence: MIN,2 Lab evidence of hypomagnesemia: • Magnesium <= 1.2 (age < 19) • Magnesium <= 1.0 (age >= 19) (+/-) Medication evidence of treatment for hypomagnesemia: • Magnesium gluconate • Magnesium • Magnesium sulfate • Magnesium citrate Satisfying evidence: Documentation of hypomagnesemia	✔	✔	Lab evidence of hypomagnesemia (+/- medication evidence of treatment for hypomagnesemia) without documentation of hypomagnesemia	LOW MAGNESIUM There is evidence of low magnesium. Please document any associated diagnosis.	✔
24008 Triggering evidence: MIN,2 Lab evidence of hypermagnesemia: • Magnesium >=3 (age < 19) • Magnesium >= 4.7 (age >= 19) (+/-) Medication evidence of treatment for hypermagnesemia: • Calcium chloride • Calcium gluconate Satisfying evidence: Documentation of hypermagnesemia	✔	✔	Lab evidence of hypermagnesemia (+/- medication evidence of treatment for hypermagnesemia) without documentation of hypermagnesemia	HIGH MAGNESIUM There is evidence of high magnesium. Please document any associated diagnosis.
51001002 Triggering evidence: MIN,2 Lab evidence of hypophosphatemia: • Phosphorus <2 (age >= 19 years) (+/-) medication evidence of treatment of hypophosphatemia: • Phosphate Satisfying evidence: Documentation of hypophosphatemia	✔	✔	Lab evidence of hypophosphatemia (+/- medication evidence of treatment for hypophosphatemia) without documentation of hypophosphatemia	LOW PHOSPHATE There is lab evidence of low phosphate. Please document any associated diagnosis.
51001003 Triggering evidence: MIN,2 Lab evidence of hyperphosphatemia: • Phosphorus >4.5 (age >= 19 years) (+/-) Medication evidence of treatment of hyperphosphatemia: • Calcium acetate • Lanthanum carbonate • Sevelamer • Sucroferric oxyhydroxide • Sodium chloride IV Satisfying evidence: Documentation of hyperphosphatemia	✔	✔	Lab evidence of hyperphosphatemia (+/- medication evidence of treatment for hyperphosphatemia) without documentation of hyperphosphatemia	HIGH PHOSPHATE There is evidence of high phosphate. Please document any associated diagnosis.
51002782 Triggering evidence: MIN, 2 Lab evidence of SIADH: • Sodium <132 • Serum Osmolality <280 • Urine Osmolality >100 AND treatment evidence of SIADH: • Fluid restriction • 3% NS NO documentation of impaired kidney function: • Acute kidney injury • CKD NO lab evidence of hyperglycemia OR documentation of hyperglycemia: • Hyperglycemia • Glucose >400 Satisfying evidence: Documentation of SIADH: • Syndrome of innapropriate antidiuretic hormone secretion	✔	✔	Lab and treatment evidence of SIADH without documentation of SIADH	ABNORMAL SODIUM AND OSMOLALITY There is lab evidence of abnormal sodium and osmolality and evidence of fluid restriction or administration of 3%NS. Please document any associated diagnosis.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
26004^A Triggering evidence: Lab evidence of acidosis : • Lactate > than 4 mmol/L Satisfying evidence: Documentation of lactic acidosis : • D-lactic acidosis • Lactic acidosis • Hypertrophic cardiomyopathy with hypotonia and lactic acidosis • Pyruvate dehydrogenase complex deficiency • Infantile encephalopathy and lactic acidosis	✔	✔	Lab evidence of lactic acidosis without documentation of lactic acidosis (age: > 18 years)	ELEVATED LACTATE There is evidence of elevated lactate. Please document any associated diagnosis.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
13000^A Triggering evidence: Documentation of albumin <= 3.4 OR BMI < 19 OR Medication evidence of malnutrition: • Megace • Marinol • Megestrol • Protonix • Tetracyclic antidepressants OR Supporting evidence of malnutrition: • Underweight • Tube feeding • Failure to thrive • TPN • Sunken temples AND MIN,2 Clinical evidence of malnutrition: • Weight loss • Accumulation of fluid • Muscle atrophy • Loss of subcutaneous fat • Underweight • Cachexia • Emaciated • Failure to thrive Satisfying evidence: Documentation of the severity of malnutrition: • Mild malnutrition • Moderate malnutrition • Severe malnutrition	✔	✔	Lab or medication evidence of malnutrition, and clinical evidence of malnutrition, without documentation of severity of malnutrition (age: > 18 years)	NUTRITIONAL INDICATORS - G There is evidence of a nutritional condition, please document any associated diagnosis with severity.	✔	✔		✔
13002^A Triggering evidence:* BMI <= 19 (+/-) Clinical evidence of malnutrition: • Weight loss • Accumulation of fluid • Muscle atrophy • Loss of subcutaneous fat • Underweight • Cachexia • Emaciated • Failure to thrive OR (+/-) Medication evidence of malnutrition: • Megace • Marinol • Oxandrolone • Tetracyclic antidepressants OR (+/-) Documentation of pressure ulcer: • Pressure ulcer • Staged pressure ulcer • Plaster ulcer • Pressure injury of deep tissue • Decubitus ulcer		✔	Notification: BMI <=19 (+/- clinical or medication evidence of malnutrition or documentation of pressure ulcer) (age: > 18 years)
13003^A Triggering evidence:* BMI <= 19 (+/-) Clinical evidence of malnutrition: • Weight loss • Accumulation of fluid • Muscle atrophy • Loss of subcutaneous fat • Underweight • Cachexia • Emaciated • Failure to thrive OR (+/-) Lab evidence of malnutrition: • Albumin <= 2.9 OR (+/-) Medication evidence of malnutrition: • Marinol • Megace • Protonix • Oxandrolone • Tetracyclic antidepressants		✔	Notification: Documentation of BMI less than or equal to 19 (+/- clinical, lab, or medication evidence of malnutrition) (age: > 18 years)
13005 Triggering evidence: Documentation of malnutrition (+/-) Clinical evidence of malnutrition: • Weight loss • Accumulation of fluid • Muscle atrophy • Loss of subcutaneous fat • Underweight • Cachexia • Emaciated • Failure to thrive OR (+/-) Medication evidence of malnutrition: • Marinol • Megace • Oxandrolone • Tetracyclic antidepressants • OR (+/-) BMI < 19 (age > 19 years) OR percentile evidence of malnutrition (age < 19 years): • BMI at or below 3rd percentile for age • Weight at or below 3rd percentile for age Satisfying evidence: Documentation of the severity of malnutrition: • Mild malnutrition • Moderate malnutrition • Severe malnutrition • Mild protein-calorie malnutrition • Moderate protein-calorie malnutrition • Severe protein-calorie malnutrition	✔	✔	Documentation of malnutrition (+/- BMI <19, clinical or medication evidence of malnutrition) without documentation of the severity of malnutrition	MALNUTRITION Please specify the severity of malnutrition.	✔	✔		✔
13006^A Triggering evidence: Documentation of TPN OR tube feeding: • TPN • Gastrostomy feeding • Enteral feeding • Nasogastric feeding • PEG tube feeding • IV or peripheral line feeding (+/-) BMI <=19 (+/-) Clinical evidence of malnutrition: • Weight loss • Accumulation of fluid • Muscle atrophy • Loss of subcutaneous fat • Underweight • Cachexia • Emaciated • Failure to thrive (+/-) Medication evidence of malnutrition: • Marinol • Megace • Oxandrolone • Tetracyclic antidepressants Satisfying evidence: Documentation of the severity of malnutrition: • Including but not limited to: • Mild malnutrition • Moderate malnutrition • Severe malnutrition • Mild protein-calorie malnutrition • Moderate protein-calorie malnutrition • Severe protein-calorie malnutrition OR documentation of the absence of malnutrition	✔		Documentation of TPN or tube feeding (+/- BMI <=19, clinical 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 Triggering evidence: Evidence of BMI < 19 (age >= 19) OR medication evidence of malnutrition: • Marinol • Megace • Protonix • Oxandrolone • Tetracyclic antidepressants OR supporting evidence of malnutrition: • Underweight • Tube feeding • Failure to thrive • TPN • Sunken temples OR percentile evidence of malnutrition (age < 19 years): • BMI at or below 3rd percentile for age • Weight at or below 3rd percentile for age AND MIN,2 clinical evidence of malnutrition: • Weight loss • Accumulation of fluid • Muscle atrophy • Loss of subcutaneous fat • Underweight • Cachexia • Emaciated Satisfying evidence: Documentation of the severity of malnutrition: • Mild malnutrition • Moderate malnutrition • Severe malnutrition • Mild protein-calorie malnutrition • Moderate protein-calorie malnutrition • Severe protein-calorie malnutrition	✔	✔	BMI <=19 or medication evidence of malnutrition, and clinical evidence of malnutrition, without documentation of severity of malnutrition	NUTRITIONAL INDICATORS - C There is evidence of a nutritional condition, please document any associated diagnosis with severity.	✔	✔
13008^A Triggering evidence:* BMI <= 19.5 (+/-) Clinical evidence of malnutrition: • Weight loss • Accumulation of fluid • Muscle atrophy • Loss of subcutaneous fat • Underweight • Cachexia • Emaciated • Failure to thrive (+/-) Lab evidence of malnutrition: • Albumin <= 3.4 (+/-) Medication evidence of malnutrition: • Marinol • Megace • Protonix • Oxandrolone • Tetracyclic antidepressants		✔	Notification: Documentation of BMI less than or equal to 19.5 (+/- clinical, lab, or medication evidence of malnutrition) (age: >= 21 years)
13009^A Triggering evidence: Documentation of malnutrition (+/-) BMI <=19 (+/-) Clinical evidence of malnutrition: • Weight loss • Accumulation of fluid • Muscle atrophy • Loss of subcutaneous fat • Underweight • Cachexia • Emaciated • Failure to thrive (+/-) Medication evidence of malnutrition: • Marinol • Megace • Oxandrolone • Tetracyclic antidepressants Satisfying evidence: Documentation of the severity of malnutrition: • Mild • Moderate • Severe	✔	✔	Documentation of malnutrition (+/- BMI <=19, clinical 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 Triggering evidence:* MIN,2 Clinical evidence of ASPEN Criteria: • Accumulation of fluid • Decline in functional status • Inadequate dietary energy intake • Inadequate food diet • Loss of subcutaneous fat • Muscle atrophy OR BMI <= 19 (+/-) vital signs evidence of ASPEN Criteria: • Body height • Body weight		✔	Notification: Documentation of BMI less than or equal to 19 or clinical evidence of ASPEN criteria (+/- evidence of height or weight) (age: > 18 years)
13013^A Triggering evidence: BMI <= 19 Satisfying evidence: Clinical evidence of malnutrition: • Anorexia • Cachexia • Malnutrition • Recent weight loss • Underweight • Unintentional weight loss	✔		Documentation of BMI <=19 without clinical evidence of malnutrition (age: > 18 years)	LOW BMI There is evidence of BMI less than or equal to 19. Please provide any associated diagnosis or supporting indicators.	✔
40206^P Triggering evidence:* Documentation of BMI <5th percentile for age		✔	Pediatric notification: Documentation of BMI below the 5th percentile for age
40211^P Triggering evidence: Documentation of failure to thrive OR feeding difficulties: • Including but not limited to: • Difficulty eating • Failure to thrive • Feeding problem • Insufficient fluid intake (+/-) evidence of malnutrition: • BMI <= 3rd percentile for age • Weight <= 3rd percentile for age Satisfying evidence: Documentation of malnutrition : • Including but not limited to: • Acute malnutrition • Malnutrition	✔	✔	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.	✔	✔	✔	✔
51002164^A Triggering evidence: Documentation of BMI < 19.9 Satisfying evidence: Documentation of associated diagnosis: • Malnutrition • Cachexia • Underweight • Failure to thrive • Abnormal weight loss • Eating disorder	✔	✔	Documentation of BMI < 19.9 without documentation of associated diagnosis (age: >18)	LOW BMI - B There is documentation of BMI < 19.9. Please document any associated diagnosis.	✔
Malnutrition-004^A Triggering evidence: Documentation of BMI <= 19 (+/-) clinical evidence of malnutrition: • ASPEN Criteria • Underweight • Cachexia • Emaciated • Homeless • Failure to thrive (+/-) medication evidence of malnutrition: • Marinol • Megace • Protonix • Oxandrolone • Tetracyclic antidepressants (+/-) documentation of pressure ulcer Satisfying evidence: Documentation of severity of malnutrition: • Mild malnutrition • Moderate malnutrition • Severe malnutrition • Mild protein-calorie malnutrition • Moderate protein-calorie malnutrition • Severe protein-calorie malnutrition	✔	✔	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 Triggering evidence: MIN,3 Documentation of BMI <= 19 OR medication evidence of malnutrition: • Marinol • Megace • Protonix • Oxandrolone • Tetracyclic antidepressants OR clinical evidence of malnutrition: • ASPEN Criteria • Underweight • Cachexia • Emaciated • Homeless • Failure to thrive OR evidence of tube feeding: • Gastrostomy tube or button • Enteral feeding • Nasogastric tube • PEG tube • GJ tube (+/-) documentation of malnutrition: • Malnutrition • Kwashiorkor • Nutritional marasmus Satisfying evidence: Documentation of severity of malnutrition	✔	✔	BMI <=19, medication evidence, or clinical evidence of malnutrition (+/- documentation of malnutrition) without documentation of severity of malnutrition	NUTRITIONAL INDICATORS - E There is evidence of a nutritional condition, please document any associated diagnosis with severity.	✔	✔
Malnutrition-006^A Triggering evidence: Documentation of malnutrition: • Kwashiorkor • Malnutrition • Nutritional marasmus Satisfying evidence: BMI <= 19 (+/-) Clinical evidence of malnutrition: • ASPEN Criteria • Underweight • Cachexia • Emaciated • Homeless • Failure to thrive (+/-) Medication evidence of malnutrition: • Marinol • Megace • Protonix • Oxandrolone- androgenic hormones • Tetracyclic antidepressants	✔	✔	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-007^A Triggering evidence: Documentation of malnutrition : • Kwashiokor • Malnutrition • Nutritional marasmus Satisfying evidence: Documentation of protein-calorie malnutrition with severity: • Mild protein-calorie malnutrition • Moderate protein-calorie malnutrition • Severe protein-calorie malnutrition	✔	✔	Documentation of malnutrition without documentation of protein-calorie malnutrition and severity (age: > 18 years)	MALNUTRITION TYPE/SEVERITY Please document the type and severity of malnutrition.	✔	✔
Malnutrition-008^A Triggering evidence: MIN,2 Clincial evidence of failure to thrive OR cachexia: • Abnormal weight loss • Loss of subcutaneous fat • Muscle atrophy • Loss of hair • Decrease in appetite AND BMI <= 19 OR Albumin <= 3.0 OR Prealbumin <= 15 Satisfying evidence: Documentation of failure to thrive OR cachexia	✔	✔	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 a nutritional condition, please document any associated diagnosis with severity.	✔	✔	✔	✔
PedMalnutrition-003 Triggering evidence: Documentation of TPN OR tube feeding : • TPN • Gastrostomy feeding • Enteral feeding • Nasogastric feeding • PEG tube feeding • IV or Peripheral line feeding (+/-) documentation of BMI or weight Z-scores : • Evidence of severe <-3 • Evidence of moderate <-2 • Evidence of mild <-1.645 (+/-) clinical evidence of malnutrition: • ASPEN Criteria • Underweight • Cachexia • Emaciated • Homeless • Failure to thrive (+/-) medication evidence of malnutrition: • Including but not limited to: • Marinol • Megace • Protonix • Oxandrolone • Tetracyclic antidepressants Satisfying evidence: Documentation of severity of malnutrition OR malnutrition ruled out	✔	✔	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.	✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
23001^A Triggering evidence:* Documentation of BMI >= 40 AND evidence of amputation: • Amputated lower limb • Traumatic amputation of lower extremity		✔	Notification: Documentation of BMI greater than or equal to 40 and evidence of amputation (age: > 18 years)
23003^A Triggering evidence: BMI >= 30 Satisfying evidence: Documentation of obesity OR morbid obesity	✔	✔	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	✔		✔	✔
23004^A Triggering evidence: BMI >= 25 and < 30 Satisfying evidence: Documentation of overweight: • Morbid obesity • Obesity • Overweight	✔	✔	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				✔
23005^A Triggering evidence: BMI >= 30 and <40 Satisfying evidence: Documentation of obesity	✔	✔	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				✔
23006^A Triggering evidence: BMI => 40 (+/-) Documentation of obesity Satisfying evidence: Documentation of class or type 3, severe, OR morbid obesity	✔	✔	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 documentation of BMI greater than or equal to 40 please document any associated diagnosis.	✔			✔
23007^A Triggering evidence:* MIN,2 Evidence on obesity-inducing drug: • Sulfonylureas • Corticosteroids • Atypical antipsychotics • SSRIs • Beta-adrenergic blocking agents AND documentation of obesity OR morbid obesity		✔	Notification: Documentation of obesity or morbid obesity and medication evidence of obesity-inducing drug (age: > 18 years)
23008 Triggering evidence: Documentation of obesity OR morbid obesity NO documentation of current pregnancy Satisfying evidence: Documentation of the etiology of obesity OR morbid obesity: • Any provider linked etiology to obesity or morbid obesity • Idiopathic obesity • Idiopathic morbid obesity • Multifactorial obesity • Multifactorial morbid obesity	✔	✔	Documentation of obesity or morbid obesity without documentation of the etiology of obesity or morbid obesity	OBESITY ETIOLOGY Please document the etiology of obesity or morbid obesity.	✔		✔	✔
23009 Triggering evidence: Documentation of obesity OR morbid obesity AND documentation of hypoventilation: • Obstructive sleep apnea • Breathing-related sleep disorder OR pCO2 arterial > 45 mmHg Satisfying evidence: Documentation of alveolar hypoventilation OR Pickwickian syndrome	✔	✔	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.	✔			✔
40203^P Triggering evidence: Documentation of BMI =95th percentile to <99th percentile for age >=2 years of age OR documentation of BMI >=30 but <35 for patients >=2 years of age Satisfying evidence: Documentation of obesity	✔	✔	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 less than 35. Please document any associated diagnosis.				✔
40204^P Triggering evidence: Documentation of BMI >=35 OR >= 99th percentile for >= 2 years of age Satisfying evidence: Documentation of severe obesity OR class 2 obesity OR class 3 obesity	✔	✔	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)	CLINICAL FINDINGS WITHOUT DIAGNOSIS 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 Triggering evidence:* Documentation of BMI >= 5th percentile but <85th percentile for age		✔	Pediatric notification: Documentation of BMI between the 5th and 85th percentile for age
40208^P Triggering evidence:* Documentation of BMI >= 85th percentile but <95th percentile for age		✔	Pediatric notification: Documentation of BMI between the 85th and 95th percentile for age
40209^P Triggering evidence:* Documentation of BMI >= 95th percentile for age		✔	Pediatric notification: Documentation of BMI at or above the 95th percentile for age
51002165 Triggering evidence: Documentation of BMI >40 OR documentation of BMI >35 AND documentation of associated diagnosis: • Coronary arteriosclerosis • Diabetes mellitus • Hypertension • Sleep apnea • Non-alcoholic fatty liver Satisfying evidence: Documentation of morbid obesity OR class 3 obesity	✔	✔	Documentation of BMI greater than 40 or documentation of BMI greater than 35 with clinical diagnosis without documentation of morbid obesity or Class 3 obesity	BMI GREATER THAN 35 There is documentation of BMI greater than 35. Please document any associated diagnosis	✔			✔
Obesity-002^A Triggering evidence: Documentation of BMI >= 36 Satisfying evidence: Documentation of class 2, class 3, severe, OR morbid obesity	✔	✔	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.	✔		✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51001182^A Triggering evidence: Documentation of a thyroid medication: • Levothyroxine • Liothyronine • Tiratricol • Thyroglobulin Satisfying evidence: Documentation of thyroid condition: • Indlucing but not limited to: • Hypothyroidism • Thyroidectomy • Thyroiditis	✔	✔	Documentation of a thyroid medication without documentation of a thyroid condition	THYROID There is documentation of a thyroid medication. Please document any associated diagnosis.	✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51000302^A Triggering evidence: Creatinine > 2 mg/dL AND urine sodium > 40 mEq OR Documentation of diuretics OR clinical evidence of renal insufficiency: • Acute papillary necrosis • Lower urinary tract obstruction • Dehydration • Acute tubular necrosis • Obstruction of ureter OR documentation of renal insufficiency Satisfying evidence: Documentation of acute renal failure, acute kidney injury OR other renal disease	✔	✔	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.	✔	✔	✔	✔
51002082 Triggering evidence: Documentation of acute kidney injury AND documentation of hypotension or shock OR evidence of nephrotoxic medications or IV contrast: • IV contrast • Cyclosporine • Cisplatin • Aminoglycosides • Amphotericin B OR documentation of dialysis or continuous renal replacement therapy AND NO documentation of end stage renal disease Satisfying evidence: Documentation of the presence OR absence of acute tubular necrosis	✔	✔	Documentation of acute kidney injury and evidence of acute tubular necrosis without documentation of the presence or absence of acute tubular necrosis	ACUTE KIDNEY INJURY There is documentation of acute kidney injury. Please document the presence or absence of any associated diagnosis.		✔
51002542 Triggering evidence: Documentation of malignancy: • Malignant neoplasm • Carcinoid tumor • Metastatic carcinoma AND MIN,2 lab evidence of tumor lysis syndrome: • Potassium >= 6 • Uric acid >= 8 • Phosphorus >=4.5 • Calcium <= 7 (+/-) medication evidence: • Rasburicase • Allopurinol • Febuxostat • Sodium bicarbonate IV Satisfying evidence: Documentation of the presence or absence of tumor lysis syndrome	✔	✔	Documentation of malignancy and lab evidence of tumor lysis syndrome (+/- medication evidence of tumor lysis syndrome) without documentation of the presence or absence of tumor lysis syndrome	UNSPECIFIED CLINICAL CONDITION - H There is documentation of malignancy and abnormal lab values. Please document associated diagnosis.		✔
6000 Triggering evidence: Documentation of acute renal insufficiency OR pre-renal azotemia (+/-) clinical OR lab evidence of acute renal failure: • Fatigue • Peripheral edema • Nausea • Acute confusion • Shortness of breath • Creatinine increase by 0.3 mg/dL within 48 hours (baseline >=1.3 mg/dL) Satisfying evidence: Documentation of acute renal failure OR acute kidney injury	✔	✔	Documentation of acute renal insufficiency or pre-renal azotemia (+/- clinical or lab evidence of acute renal failure) without documentation of acute renal failure	RENAL There is documentation of acute renal insufficiency or pre-renal azotemia. Please document a more specific diagnosis, if known.	✔	✔	✔	✔
6001^A Triggering evidence: Creatinine increase by 50% within 7 days: • Baseline >= 1.3 mg/dL OR creatinine increase by 0.3 mg/dL within 48 hours: • Baseline >= 1.3 mg/dL (+/-) Clinical evidence of ARF: • Acute confusion • Peripheral edema • Shortness of breath • Nausea • Itching of skin (+/-) Clinical causes of ARF/AKI: • Kidney stones • Bladder outflow obstruction • Diabetes mellitus • Sepsis AND NO Documentation of CKD AND NO Documentation of negated ARF/AKI Satisfying evidence: Documentation of acute renal failure OR chronic progressive renal failure	✔	✔	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 Triggering evidence:* Documentation of creatinine >= 1.5 mg/dL AND Documentation of prerenal azotemia OR MIN,2 Documentation of dehydration (+/-) Evidence of dehydration: • Including but not limited to: • Astenia • Cramp • Lightheadedness • Nausea • Mucous membrane dryness • Excessive thirst (+/-) Evidence of acute renal failure: • Including but not limited to: • Acute confusion • Peripheral edema • Shortness of breath • Nausea • Itching of skin NO Documentation of ATN, CKD, ARF/AKI OR ESRD		✔	Notification: Documentation of creatinine >= 1.5 and prerenal azotemia or dehydration (+/- clinical evidence of acute renal failure or dehydration) (age: > 18 years)
6006 Triggering evidence: Documentation of acute renal failure : • Including but not limited to: • Acute renal failure • Acute kidney injury • Acute drug induced renal failure • Acute on chronic renal failure • Acute renal failure on dialysis (+/-) lab OR clinical evidence of acute renal failure: • Creatinine increase by 0.3 mg/dL within 48 hours (baseline >=1.3 mg/dL) • Acute confusion • Peripheral edema • Shortness of breath • Nausea • Itching of skin AND NO documentation of pre-renal AKI Satisfying evidence: Documentation of site of kidney insult or injury: • Acute necrosis of cortex of kidney • Acute nephrotic syndrome • Acute papillary necrosis • Acute tubular necrosis • Postoperative acute tubular necrosis	✔	✔	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 renal failure. Please document a more specific diagnosis, if known.		✔
6008^A Triggering evidence:* Documentation of acute renal failure (+/-) Clinical evidence of acute renal failure: • Including but not limited to: • Acute confusion • Peripheral edema • Shortness of breath • Nausea • Itching of skin (+/-) Lab evidence of acute renal failure: • Creatine increase by 0.3 mg/dL within 48 hrs • Creatine increase by 50% within 7 days • (Baseline >= 1.3 mg/dL)		✔	Notification: Documentation of acute renal failure (+/- clinical or lab evidence of acute renal failure) (age: > 18 years)
6009 Triggering evidence: Documentation of acute renal failure : • Acute drug-induced renal failure • Acute kidney injury • Acute renal failure due to sepsis • Crush syndrome • Acute renal failure due to procedure (+/-) Evidence of acute renal failure: • Acute confusion • Decreased urinary output • Peripheral edema • Fatigue • Creatine increase by 0.3 mg/dL within 48 hrs (baseline >= 1.3 mg/dL) Satisfying evidence: Documentation of the etiology of acute renal failure : • Any provider link to cause of acute renal failure AND NOT Documentation of acute on chronic renal failure OR acute renal failure	✔	✔	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.	✔
6010^A Triggering evidence: Documentation of acute renal failure (+/-) Clinical evidence of acute renal failure: • Decreased urine output • Peripheral edema • Acute confusion • Nausea • Asthenia Satisfying evidence: Urine sodium > 40 meq/L OR Creatinine >= 1.5 mg/dL OR Documentation of the etiology of acute renal failure: • Diabetes mellitus • Hypertensive renal failure • Glomerulonephritis • Urinary tract obstruction • Kidney stone • Any provider linked etiology of acute renal failure	✔	✔	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* Triggering evidence: MIN,2 Documentation of acuity of renal failure OR kidney disease: • Acute • Chronic (+/-) Evidence of kidney disease: • Edema of extremity • Hypertension • Dysnea • Hypercalcemia • Hyperkalemia (+/-) Lab evidence of kidney disease: • Serum Creatine • GFR AND NO Documenation of acute renal failure or chronic kidney disease		✔	Notification: Documentation of the acuity of kidney failure or disease (+/- clinical or lab evidence of kidney disease)		✔	✔	✔	✔
9005* Triggering evidence: Documentation of abbreviation AKI AND No documentation of acute kidney injury: • Acute renal failure • Acute kidney injury • Traumatic acute renal failure • Acute kidney failure	✔	✔	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 Triggering evidence: Documentation of acute kidney injury OR Documentation of intra-renal disease OR intrinsic renal disease (+/-) Clinical OR lab evidence of acute kidney injury: • Acute confusion • Peripheral edema • Shortness of breath • Nausea • Itching of skin • Decreased urine output • Creatinine increase by 0.3mg/dL within 48 hrs (baseline >= 1.3 mg/dL) Satisfying evidence: Documentation of acute tubular necrosis	✔	✔	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, 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.	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
6004^A Triggering evidence: Clinical evidence of etiology of acute tubular necrosis (ATN): • Including but not limited to: • Antineoplastic agent • Acute papillary necrosis • Nephrotoxin • Pancreatitis • Septic shock • Ischemia of kidney AND Lab evidence of acute tubular necrosis (ATN): • FENa > 2% • Urine sodium >40 Satisfying evidence: Documentation of acute tubular necrosis	✔	✔	Clinical and lab evidence of acute tubular necrosis without documentation of acute tubular necrosis (age: >18)	RENAL DISORDER There is evidence of high fractional excretion of sodium or urine sodium. Please document any associated diagnosis.		✔
6007^A Triggering evidence:* Documentation of acute tubular necrosis: • Acute tubular necrosis • Legal abortion with renal tubular necrosis • Illegal abortion with renal tubular necrosis • Post-traumatic acute tubular necrosis • Postoperative acute tubular necrosis AND (+/-) FENa > 2% OR urine sodium > 40 meq/L		✔	Notification: Documentation of acute tubular necrosis (+/- lab evidence) (age: > 18 years)

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51001202^P Triggering evidence: Documentation of chronic kidney disease: • Chronic renal failure • End-stage renal disease • Acute-on-chronic renal failure AND (+/-) clinical evidence of chronic kidney disease : • Anemia • Fatigue • Headache • Hypertension • Foot swelling OR documentation of serum creatinine OR documentation of GFR <=59 Satisfying evidence: Documentation of the stage of chronic kidney disease: • Chronic kidney disease stages 1-5	✔	✔	Pediatric: Documentation of chronic kidney disease (+/- clinical evidence of chronic kidney disease) without documentation of stage of disease	KIDNEY DISEASE - B Please document the stage of chronic kidney disease.	✔		✔	✔
51002462 Triggering evidence: Documentation of chronic kidney disease: • Including but not limited to: • Chronic kidney disease • Acute-on-chronic renal failure AND documentation of dialysis: • Hemodialysis • Renal dialysis • Peritoneal dialysis • Continuous ambulatory peritoneal dialysis • Dependence on dialysis Satisfying evidence: Documentation of end stage renal disease: • Including but not limited to: • End stage renal disease • End stage renal failure	✔	✔	Documentation of chronic kidney disease and dialysis without documentation of end stage renal disease	CHRONIC KIDNEY DISEASE There is documentation of chronic kidney disease and dialysis. Please document any associated diagnosis.
9000 Triggering evidence: Documentation of CKD AND lab evidence of GFR <= 59 (+/-) serum creatinine OR clinical evidence of CKD: • Dyspnea • Hypercalcemia • Hypertension • Impaired cognition • Edema of extremity Satisfying evidence: Documentation of stage of CKD: • Stage 1 • Stage 2 • Stage 3 (A&B) • Stage 4 • Stage 5 • End-stage renal disease	✔	✔	Documentation and lab evidence of chronic kidney disease (+/- clinical evidence of chronic kidney disease or serum creatinine) without documentation of the stage of chronic kidney disease	KIDNEY DISEASE Please document the stage of chronic kidney disease.	✔	✔	✔	✔
9001^A Triggering evidence:* No documentation of acute renal failure AND Documentation of ESRD (+/-) Documentation of ESRD with dialysis OR Documentation of CKD AND Evidence of dialysis: • Inluding but not limited to: • Dialysis graft • Dialysis fistula • Dialysis catheter • Hemodialysis • Peritoneal dialysis		✔	Notification: Documentation of ESRD (+/- dialysis) or documentation of CKD with evidence of dialysis and no documentation of acute renal failure
KidneyDisease-001 Triggering evidence: Documentation of chronic kidney disease stage 3 AND (+/-) Documentation of 'avoid nephrotoxic drugs' OR(+/-) Lab evidence of stage 3a: • GFR 45 to 59 OR (+/-) Lab evidence of stage 3b: • GFR 30 to 44 Satisfying evidence: Documentation of chronic kidney disease stage 3a or 3b	✔	✔	Documentation of chronic kidney disease stage 3 (+/- documentation of avoidance of nephrotoxic drugs or lab evidence of elevated GFR) without documentation of specificity of chronic kidney disease stage 3a or 3b	CKD STAGE 3 SPECIFICITY Please further classify the stage 3 chronic kidney disease.
KidneyDisease-002 Triggering evidence: Lab evidence of creatinine >1.5 Satisfying evidence: Documentation of acute renal failure OR chronic kidney disease	✔	✔	Lab evidence of creatinine > 1.5 without documentation of acute or chronic kidney disease	ELEVATED CREATININE There is evidence of creatinine >1.5. Please document any associated diagnosis.			✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12004 Triggering evidence: Documentation of hematuria: • Blood in urine • Upper urinary tract hematuria • Renal hematuria • Hematuria syndrome Satisfying evidence: Documentation of the type of hematuria: • Microscopic hematuria • Persistent hematuria • Recurrent hematuria • Benign hematuria • Nephritic syndrome	✔	✔	Documentation of hematuria without documentation of the type of hematuria	HEMATURIA Please document the type of hematuria.	✔			✔
12013 Triggering evidence: Documentation of urethral stricture: • Urethral stricture • Submeatal urethral stricture • Traumatic urethral stricture • Postoperative urethral stricture Satisfying evidence: Documentation of the type of urethral stricture: • Traumatic urethral stricture • Idiopathic urethral stricture • Post-inflammatory urethral stricture • Post-catheterization urethral stricture • Urethral stricture due to and following procedure	✔	✔	Documentation of urethral stricture without documentation of the type of urethral stricture	URETHRAL STRICTURE Please document the type of urethral stricture.
12014 Triggering evidence: Documentation of urinary calculus: • Urolith • Urolithiasis • Kidney stone • Staghorn calculus • Hydronephrosis due to calculus of kidney or ureter (+/-) clinical evidence of urinary calculus: • Blood in urine • Fever • Urgent desire to urinate • Abnormal urine odor • Flank pain Satisfying evidence: Documentation of the specific site of the urinary calculus: • Calculus of lower urinary tract • Kidney stone • Ureteric stone • Hydronephrosis due to calculus of kidney or ureter • Urinary bladder stone	✔	✔	Documentation of urinary calculus (+/- clinical evidence of urinary calculus) without documentation of the site of the urinary calculus	URINARY CALCULUS Please document the site of the urinary calculus, if known.	✔
12015 Triggering evidence: Documentation of renal calculus, ureteric calculus, bladder calculus, OR urethra calculus: • Urolith • Urolithiasis • Staghorn calculus • Hydronephrosis due to calculus of kidney or ureter • Kidney stone Satisfying evidence: Documentation of presence or absence of hydronephrosis OR obstruction : • Caliectasis • Hydronephrosis • Non-obstructive calculus • Non-obstructive kidney stone • Stricture of ureter • Urinary tract obstruction	✔	✔	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.	✔			✔
51002784 Triggering evidence: Documentation of CKD stage 4 or 5 or ESRD AND lab evidence of secondary hyperparathyroidism: • Phosphorus > 4.5 • PTH > 94 (+/-) medication evidence of treatment for secondary hyperparathyroidism: • Sensipar Satisfying evidence: Documentation of secondary hyperparathyroidism	✔	✔	Documentation of CKD stage 4 or 5 or ESRD and lab evidence (+/- medication evidence) of secondary hyperparathyroidism without documentation of secondary hyperparathyroidism	ELEVATED PTH AND PHOSPHORUS There is evidence of elevated PTH and phosphorus and documentation of CKD stage 4-5 or ESRD. Please document any associated diagnosis.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
16011* Triggering evidence: Documentation of urinary tract infection: • Acute cystitis • Chronic cystitis • Cystitis • Infectious disorder of kidney • Urinary tract infection AND documentation of a urinary device: • Nephrostomy tube • Ureteric stent • Uretheral stent • Urinary catheter		✔	Notification: Documentation of a urinary tract infection and the presence of a urinary device
16014 Triggering evidence: Documentation of urinary tract infection: • Including, but not limited to: • Urinary tract infection • Cystitis • Acute cystitis • Chronic cystitis • Infective disorder of kidney • Satisfying evidence: Documentation of urinary tract infection present on admission status OR documentation of the presence of urinary tract infection on the history and physical document OR documentation of negated uninary tract infection on the history and physical document	✔	✔	Documentation of urinary tract infection without documentation of present on admission status	URINARY TRACT INFECTION POA - B Please document whether the UTI was present on admission.	✔
16016* Triggering evidence: Documentation of UTI present on admission : • Including, but not limited to: • Urinary tract infection • Cystitis • Acute cystitis • Chronic cystitis • Infective cystitis OR documentation of UTI in a H&P document: • Including, but not limited to: • Urinary tract infection • Cystitis • Acute cystitis • Chronic cystitis • Infective cystitis		✔	Notification: Documentation of urinary tract infection present on admission
16029 Triggering evidence: Documentation of a urinary device: • Nephrostomy tube • Ureteric stent • Uretheral stent • Urinary catheter AND documenation of UTI: • Including, but not limited to: • Urinary tract infection • Cystitis • Acute cystitis • Chronic cystitis • Infective cystitis Satisfying evidence: Documentation of UTI due to urinary device: • Any provider linked cause of UTI and urinary device OR documentation of UTI not caused by urinary device: • Any negated cause of UTI by urinary device	✔	✔	Documentation of a urinary tract infection and a urinary device without documentation of the relationship of the urinary tract infection and the urinary device	UTI - URINARY DEVICE - B There is documentation of a urinary device and a urinary tract infection. Please document whether these are causally related.	✔		✔	✔
16031 Triggering evidence: Documentation of catheter associated urinary tract infection Satisfying evidence: Documentation of catheter associated urinary tract infection present on admission status OR documentation of the presence of catheter associated urinary tract infection on a history and physical document OR documentation of negated urinary tract infection on the history and physical document	✔	✔	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 Triggering evidence: Documentation of pyelonephritis : • Pyelonephritis • Mumps nephritis • Infective ureteritis • Candida ureteritis • Emphysematous pyelonephritis (+/-) clinical evidence of pyelonephritis: • Abdominal pain • Backache • Blood in urine • Fever with chills • Flank pain Satisfying evidence: Documentation of the acuity of pyelonephritis: • Acute • Acute on chronic • Chronic	✔	✔	Documentation of pyelonephritis (+/- clinical evidence of pyelonephritis) without documentation of acuity of pyelonephritis	PYELONEPHRITIS Please document the acuity of pyelonephritis.	✔			✔
51001282 Triggering evidence: Documentation of urinary tract infection in the emergency department : • Cystitis • Nephritis • Pyelonephritis • Urethritis • Urinary tract infection Satisfying evidence: Documentation of the presence or absence of urinary tract infection in the inpatient documentation : • Cystitis • Nephritis • Pyelonephritis • Urethritis • Urinary tract infection	✔	✔	Documentation of UTI in the emergency department without documentation of UTI in the inpatient documentation	URINARY TRACT INFECTION - B UTI is documented in the emergency department but has not been documented after admission. Please clarify the presence or absence of this diagnosis.	✔
51001283 Triggering evidence: Documentation of catheter associated urinary tract infection in the emergency department Satisfying evidence: Documentation of the presence or absence of catheter associated urinary tract infection in the inpatient documentation	✔	✔	Documentation of catheter associated UTI in the emergency department without documentation of catheter associated UTI in the inpatient documentation	URINARY TRACT INFECTION - C 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.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51000386 Triggering evidence: Documentation of Uterine Cancer Satisfying evidence: Documentation of the site of cancer within the uterus	✔	✔	Documentation of uterine cancer without documentation of the site of cancer within the uterus	UTERINE CANCER Please document the site of cancer within the uterus.
51000402 Triggering evidence: Documentation of cervical cancer Satisfying evidence: Documentation of the site in cervix: • Wall of cervix • Lip of cervix • Angle of cervix • Surface of uterine cervix	✔	✔	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 Triggering evidence: Documentation of fallopian tube cancer Satisfying evidence: Documentation of the laterality of fallopian tube cancer OR Documentation of the site of fallopian tube cancer	✔	✔	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 Triggering evidence: Documentation of ovarian cancer: • Ovarian cancer including but not limited to: • Epithelial cancer of ovary • Germ cell tumor of ovary • Stromal cell tumor of ovary • Malignant tumor of ovary Satisfying evidence: Documentation of laterality of affected ovary: • Right • Left • Bilateral	✔	✔	Documentation of ovarian cancer without documentation of the laterality of affected ovary	OVARIAN CANCER Please document the laterality of ovarian cancer.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
18012 Triggering evidence: Documentation of hypertension: • Elderly primigravida • Normal pregnancy in primigravida • Grand multipara • Multiparous • Nulliparous AND documentation of pregnancy: • Pregnant • Trimesters • Gravida (+/-) documentation of medication evidence of hypertension: • Beta-blocking agent • Calcium channel blocker • Angiotensin II receptor blocker • Diuretic (+/-) documentation of gravida OR para: • Elderly primigravida • Normal pregnancy in primigravida • Grand multipara • Gravida more than 10 • Nulliparous Satisfying evidence: Documentation of the type of hypertension : • Rebound hypertension • Malignant hypertension • Intermittent hypertension • Benign hypertension • Essential hypertension • Pregnancy-induced hypertension	✔	✔	Documentation of hypertension and pregnancy (+/- medication evidence of hypertension or documentation of gravida para) without documentation of the type of hypertension	HYPERTENSION TYPE - OBSTETRICS Please document the type of hypertension, if known.	✔	✔		✔
51000902 Triggering evidence: Evidence of labor: • Cervix dilated • Effacement of cervix • Premature rupture of membranes • Preterm premature rupture of membranes • Ruptured membranes AND documentation of less than 37 weeks of gestation Satisfying evidence: Documentation of preterm labor	✔	✔	Evidence of preterm labor without documentation of preterm labor	EVIDENCE OF LABOR There is evidence of labor and documentation of less than 37 weeks of gestation. Please document any associated diagnosis.	✔	✔		✔
51000923* Triggering evidence: Documentation of pregnancy AND documentation of relevant infection during pregnancy: • Including but not limited to: • Zika virus disease • Toxoplasmosis • Gonorrhea • Human immunodeficiency virus infection • Hepatitis C virus • Urinary tract infection • Streptococcus agalactiae • Group B Streptococcus carrier • Chlamydial infection	✔	✔	Notification: Documentation of relevant infection during pregnancy	There is documentation of a gynecological and/or other relevant infection during this pregnancy
51000982 Triggering evidence: Documentation of delivery : • Birth • Delivered vaginally • Delivery procedure AND documentation of perineal laceration OR repair: • Laceration of perineum • Repair of obstetric laceration • Repair of perineal tear Satisfying evidence: Documentation of degree OR subcategory of perineal laceration: • First degree perineal laceration • Second degree perineal laceration • Third degree perineal laceration • Fourth degree perineal laceration • Type 3a third degree laceration of perineum • Type 3b third degree laceration of perineum • Type 3c third degree laceration of perineum • Any provider documented severity or class of perineal laceration	✔	✔	Documentation of perineal laceration or repair with delivery without documentation of degree of laceration	PERINEAL LACERATION A delivery with perineal laceration or wound repair was documented. Please document the degree and/or subcategory of perineal laceration.	✔
51001082 Triggering evidence: Documentation of delivery OR postpartum period AND blood loss >1000 ml Satisfying evidence: Documentation of postpartum hemorrhage	✔	✔	Documentation of postpartum and blood loss > 1000 ml without documentation of postpartum hemorrhage	POSTPARTUM ASSOCIATED DISORDERS There is documentation of postpartum period with a blood loss >1000 ml. Please document the associated disorder.	✔			✔
51001402^A Triggering evidence: Medication evidence of thyroid condition: • Levothyroxine • Liothyronine • Thyroglobulin • Tiratricol • Thyroid (USP) AND documentation of pregnancy Satisfying evidence: Documentation of hypothyroidism, thyroiditis, OR thyroidectomy: • Hypothyroidism • Thyroidectomy • Completion thyroidectomy • Endoscopic total thyroidectomy • Substernal thyroidectomy • Total substernal thyroidectomy • Thyroiditis	✔	✔	Documentation of a thyroid medication during pregnancy without documentation of a thyroid condition (age: > 18 years)	OBSTETRICS -THYROID CONDITION There is medication evidence of a thyroid condition, and documentation of pregnancy. Please document any associated diagnosis.	✔			✔
51001444 Triggering evidence: Documentation of pregnancy: • Finding of gravida • Pregnant • Trimesters • Parity finding AND Documentation of gestational diabetes: • Gestational diabetes mellitus (+/-) Documentation of impaired glucose tolerance: • Abnormal glucose tolerance test • Impaired glucose tolerance • Impaired glucose tolerance test (+/-) Lab evidence of elevated hemoglobin A1C > 6.5 (+/-) Lab evidence of elevated blood glucose >= 140 mg/dL (+/-) Lab evidence of elevated glucose tolerance >= 140 mg/dL Satisfying evidence: Documentation of gestational diabetes type: • Gestational diabetes mellitus, class A1- diet controlled • Gestational diabetes mellitus, class A2- insulin controlled	✔	✔	Documentation of gestational diabetes (+/- documentation of impaired glucose tolerance, or lab evidence of elevated glucose or elevated A1C) without documentation of the type of gestational diabetes	GESTATIONAL DIABETES - TYPE Please document the type of gestational diabetes.				✔
51001462^P Triggering evidence: Documentation of thyroid medication: • Levothyroxine • Liothryonine • Thyroglobulin • Triatricol • Thyroid (USP) AND documentation of pregnancy Satisfying evidence: Documentation of thyroid condition: • Thyroidectomy • Thyroiditis • Hypothyroidism	✔	✔	Pediatric: Documentation of a thyroid medication during pregnancy without documentation of a thyroid condition	OBSTETRICS -THYROID CONDITION - B There is medication evidence of a thryoid condition during pregnancy. Please document any associated diagnosis.	✔			✔
GestDiabetes-001 Triggering evidence: Documentation of Gestational Diabetes: • Gestational diabetes mellitus • Pre-existing diabetes mellitus in pregnancy Satisfying evidence: Documentation of the type of Gestational Diabetes: • Gestational diabetes mellitus, class A1 • Gestational diabetes mellitus, class A2 • Pre-existing diabetes mellitus in pregnancy AND documentation of the associated trimester: • First trimester pregnancy • Second trimester pregnancy • Third trimester pregnancy	✔	✔	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 Triggering evidence: Documentation of Pre-eclampsia Satisfying evidence: Documentation of the severity/type of pre-eclampsia: • Hemolysis, elevated liver enzymes, and low platelet count syndrome • Mild pre-eclampsia • Moderate pre-eclampsia • Severe pre-eclampsia • Mild to moderate pre-eclampsia AND documentation of the associated trimester: • First trimester pregnancy • Second trimester pregnancy • Third trimester pregnancy	✔	✔	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.	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
40402 Triggering evidence: Documentation of chronic lung disease: • Chronic disease of respiratory system • Chronic interstitial lung disease • Chronic lung disease Satisfying evidence: Documentation of the etiology of chronic lung disease: • Any provider documentation of cause of chronic lung disease • Idiopathic chronic lung disease • Multifactorial chronic lung disease OR documentation of the specific chronic lung disease: • Asthma • Chronic obstructive pulmonary disease • Chronic bronchitis • Chronic respiratory insufficiency • Chronic tracheobronchitis • Recurrent lower respiratory tract infection	✔	✔	Pediatric: Documentation of chronic lung disease without documentation of the etiology of chronic lung disease	CHONIC LUNG DISEASE Please document the etiology of the chronic lung disease or the specific chronic lung condition.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
2200001 Triggering evidence: Documentation of Retinopathy of Prematurity (ROP) Satisfying evidence: Documentation of stage of Retinopathy of Prematurity (ROP): • Stages 0-5 AND documentation of ROP zone: • Zones 1-3 AND documentation of eye laterality of ROP	✔	✔	Pediatric: Documentation of retinopathy of prematurity without documentation of the stage, zone and eye laterality of the retinopathy of prematurity	RETINOPATHY OF PREMATURITY Please document the stage, zone, and laterality of the eye(s) affected by Retinopathy of Prematurity (ROP).

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51001123^L Triggering evidence: Lab evidence of drop in hemoglobin of greater than or equal to 2g/dL: • [requires lab evidence from lab documents] AND Documentation of recent surgery : • Including, but not limited to: • Operation • Aspiration • Dissection • Endoscopy • Grafting procedure • Microsurgery OR MIN,2 Clinical evidence of blood loss anemia: • Lethargy • Tachycardia • Dyspnea • Syncope • Cold hands • Hypotension Satisfying evidence: Documentation of acute blood loss anemia: • Acute blood loss anemia • Anemia following acute postoperative blood loss	✔	✔	Lab evidence of drop in hemoglobin of greater than or equal to 2g/dL and clinical evidence of anemia or documentation of recent surgery without documentation of acute blood loss anemia	HEMOGLOBIN DROP There is lab evidence of a drop in hemoglobin and clinical evidence of low hemoglobin or documentation of recent surgery. Please document any associated diagnosis.	✔			✔
51002923^A Triggering evidence: Hemoglobin less than 10.6 AND Hematocrit less than 32 Satisfying evidence: Documentation of the presence or absence of anemia	✔	✔	Lab evidence of anemia without documentation of the presence or absence of anemia (age: >18 years)	UNSPECIFIED CLINICAL CONDITION - L There is documentation of abnormal hemoglobin and hematocrit. Please document associated diagnosis.
8000 Triggering evidence: Lab evidence of anemia: • Hgb <13 male • Hgb <12 female • Hct <32 AND blood loss greater than 500 mL OR documentation of gastrointestinal bleed (+/-) clinical evidence of blood loss anemia OR transfusion: • Fatigue • Irregular heartbeat • Cold hands • Syncope • Hypotension NO documentation of sickle cell crisis Satisfying evidence: Documentation of blood loss anemia	✔	✔	Lab evidence of anemia and evidence of blood loss or documentation of gastrointestinal bleed (+/- clinical evidence of blood loss anemia or transfusion) without documentation of blood loss anemia	LOW HEMOGLOBIN AND HEMATOCRIT There is evidence of low hemoglobin and hematocrit and evidence of blood loss or documentation of GI bleeding. Please document any associated diagnosis.	✔			✔
80014^A Triggering evidence: Documentation of anemia Satisfying evidence: Documentation of the type of anemia : • Including but not limited to: • Anemia due to blood loss • Anemia of chronic disorder • Anemia in neoplastic disease AND documentation of the acuity of anemia : • Acute • Chronic • Acute on chronic AND documentation of the etiology of anemia: • Any physician documented cause of anemia	✔	✔	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.	✔	✔	✔	✔
8003 Triggering evidence: Documentation of anemia OR lab evidence of anemia: • Hemoglobin <13 (males >19) • Hemoglobin <12 (non-pregnant females >19) • Hematocrit <32 (age >19) • Specific pediatric reference ranges based on age (+/-) clinical evidence of blood loss: • Blood loss greater than 500 mL (+/-) clinical evidence of transfusion Satisfying evidence: Documentation of the type: • Megaloblastic anemia • Sickle cell anemia • Relative anemia • Anemia due to infection • Anemia due to copper deficiency OR documentation of etiology of anemia: • Any provider linked cause of anemia	✔	✔	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 document the type or etiology.	✔	✔	✔	✔
8004 Triggering evidence: Lab evidence of anemia: • Hemoglobin <13 (males >= 19 years) • Hemoglobin < 12 (non-pregnant females >=19 years) • Hematocrit <32 (age >=19 years) • Specific pediatric reference ranges for Hgb and Hct based on age (+/-) Evidence of blood loss: • > 500 mL (+/-) Evidence of transfusion Satisfying evidence: Explicit mention of type of anemia: • Megaloblastic anemia • Sickle cell anemia • Refractory anemia • Hemolytic anemia • Anemia due to chronic kidney disease • Normocytic anemia	✔	✔	Lab evidence of anemia (+/- clinical evidence of blood loss or a transfusion) without documentation of the type of anemia	LOW HCT/HGB There is lab evidence of low hematocrit or low hemoglobin. Please document any associated diagnosis and type.	✔	✔	✔	✔
8005 Triggering evidence: Documentation of anemia (+/-) lab evidence of anemia: • Hemoglobin <13 (males >19) • Hemoglobin <12 (non-pregnant females >19) • Hematocrit <32 (age >19) • Specific pediatric reference ranges based on age (+/-) evidence of blood loss: • Blood loss > 500 mL (+/-) evidence of transfusion: • Whole blood transfusion • Red blood cell product transfusion • Blood product transfusion Satisfying evidence: Documentation of the type of anemia: • Including, but not limited to: • Hemolytic anemia • Regenerative anemia • Aplastic anemia • Anemia due to chronic renal failure • Deficiency anemia • Drug-induced anemia	✔	✔	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 Triggering evidence: Documentation of anemia Satisfying evidence: Documentation of type of anemia: • Including but not limited to: • Anemia due to blood loss • Anemia of chronic disorder • Anemia in neoplastic disease • Secondary anemia • Megaloblastic anemia • Sickle cell anemia AND documentation of acuity of anemia: • Acute • Chronic • Acute on chronic OR Documentation of pancytopenia: • Pancytopenia • Aplastic anemia	✔	✔	Documentation of anemia without documentation of the acuity and type of anemia or documentation of pancytopenia	ANEMIA TYPE AND ACUITY There is documentation of anemia, please document the type and acuity.	✔	✔	✔	✔
Anemia-002 Triggering evidence: Documentation of anemia OR lab evidence of anemia: • Hemoglobin <13 (males >19) • Hemoglobin <12 (non-pregnant females >19) • Hematocrit <32 (age >19) • Specific pediatric reference ranges based on age Satisfying evidence: Documentation of etiology : • Any provider linked cause of anemia AND documentation of type of anemia: • Aplastic anemia • Iron deficiency anemia • Blood loss anemia • Anemia due to CKD • Pernicious anemia AND documentation of acuity of anemia: • Acute • Chronic • Acute on chronic	✔	✔	Documentation or lab evidence of anemia without documentation of the etiology, type, and acuity of anemia	EVIDENCE OF BLOOD DISORDER There is evidence of a blood disorder. Please document the type, etiology, and acuity, if known.	✔	✔	✔	✔
Anemia-004 Triggering evidence: Documentation of anemia OR lab evidence of anemia: • Hemoglobin less than OR equal to 8 • Hematocrit less than 28 (+/-) transfusion evidence of anemia (+/-) blood loss greater than 500mL Satisfying evidence: Documentation of type OR etiology of anemia: • Megaloblastic anemia • Sickle cell anemia • Iron deficiency anemia • Refractory anemia	✔	✔	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 document the type or etiology, if known.	✔	✔	✔	✔
Anemia-005 Triggering evidence: Documentation of anemia Satisfying evidence: MIN, 2 Documentation of etiology of anemia: • Any provider linked cause of anemia OR documentation of acuity of anemia: • Acute • Chronic • Acute on chronic OR documentation of type of anemia: • Including but not limited to: • Aplastic anemia • Iron deficiency anemia • Blood loss anemia • Anemia due to CKD • Pernicious anemia	✔	✔	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.	✔	✔	✔	✔
PedAnemia-001^P Triggering evidence: Lab evidence of low hemoglobin AND low hematocrit : • Specific age based Hct and Hgb AND documentation of blood loss OR transfusion OR gastrointestinal hemohhrage AND NO documentation of sickle cell crisis Satisfying evidence: Documentation of blood loss anemia	✔	✔	Pediatric: Lab evidence of anemia and clinical or lab evidence of blood loss anemia or documentation of gastrointestinal bleed without documentation of blood loss anemia	LOW HGB AND HCT - B There is evidence of low hemoglobin and hematocrit and documentation of blood loss and/or transfusion. Please document any associated diagnosis.	✔			✔
PedAnemia-002^P Triggering evidence: Documentation of anemia OR lab evidence of low hematocrit AND low hemoglobin: • Age specific low Hct and Hgb (+/-) evidence of blood transfusion (+/-) evidence of blood loss Satisfying evidence: Documentation of the type of anemia: • Including, but not limited to: • Megaloblastic anemia • Sickle cell anemia • Thalassemia • Iron deficiency anemia • Pancytopenia	✔	✔	Pediatric: Documentation or lab evidence of pediatric anemia (+/- evidence of blood loss or transfusion) without documentation of the type or etiology of anemia	BLOOD DISORDER - F There is evidence of a blood disorder, please consider documenting the type.	✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51000862^A Triggering evidence: Documentation of a bleed: • Subdural hemorrhage • Hematuria • Gastric hemorrhage • Perforation and hemorrhage • Melena AND Documentation of an anticoagulant: • Resveratrol • Aspirin • Coumadin • Heparinoinds Satisfying evidence: Documentation of whether the anticoagulant caused the bleed: • Physician documentation linking the anticoaulant to the bleed	✔	✔	Documentation of a bleed and an anticoagulation medication without documentation of whether the anticoagulant caused the bleed (age:>18 years)	BLEED There is documentation of a bleed and an anticoagulant. Please clarify whether these are causally related, if applicable.	✔		✔	✔
51002042* Triggering evidence: Documentation of Kcentra administration		✔	Notification: Documentation of Kcentra administration
51002243 Triggering evidence: Documentation of atrial fibrillation AND documentation of anticoagulation medication: • Anticoagulants • Platelet aggregation inhibitor (non-heparin) Satisfying evidence: Documentation of hypercoagulable condition OR state	✔	✔	Documentation of atrial fibrillation and anticoagulation medication without documentation of hypercoagulable condition or state	THROMBOPHILIA Anticoagulation medication and atrial fibrillation have been documented. Please document any associated conditions.
51002622^A^L Triggering evidence: Documentation of bleeding: • Blood in urine • Capillary hemorrhage • Cerebral hemorrhage • Gastrointestinal bleed • Melena AND Lab evidence of fibrinogen: • Fibrinogen <100 mg/dL AND Lab evidence of INR: • INR >1.3 AND Lab evidence of platelets: • Platelets <100,000 mcL AND Lab evidence of D-dimer: • D-dimer >1 mg/L Satisfying evidence: Documentation of the presence or absence of disseminated intravascular coagulation	✔	✔	Lab and clinical evidence of disseminated intravascular coagulation without documentation of the presence or absence of disseminated intravascular coagulation (age: >18 years)	UNSPECIFIED CLINICAL CONDITION - J There is documentation of bleeding and lab evidence of abnormal fibrinogen, INR, platelets, and D-dimer. Please document associated diagnosis.		✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51001242 Triggering evidence: Documentation of immunosuppressive medication OR therapy AND history of transplant Satisfying evidence: Documentation of immunosuppressive status	✔	✔	Documentation of immunosuppressive medication or therapy and history of transplant without documentation of immunosuppressive status	IMMUNOSUPPRESSIVE STATUS Immunosuppressive medication or therapy and transplant have been documented. Please document the patient's immune status.
51001342^A Triggering evidence: Documentation of immunosuppressant treatment OR Chimeric Antigen Receptor (CAR) T-Cells therapy: • Genetically modified T-cell • Antioneoplastic agent - mTOR inhibitor • Janus kinase inhibitor • Monoclonal antibody • Rituximab • Upadacitinib AND NO documentation of HIV OR AIDS Satisfying evidence: Documentation of immunosuppressed, immunocompromised OR immunodeficient	✔	✔	Evidence of immunosuppressant medication(s) or CAR T-cell therapy without documentation of immune status (age: >18 years)	IMMUNOSUPPRESSANT/CAR T There is evidence of immunosuppressant treatment or CAR T-cells therapy. Please document the immune status.	✔		✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
8006 Triggering evidence: Documentation of Neutropenia : • Agranulocytosis • Granulocytopenic • Neutropenia • Neutropenic disorder (+/-) lab evidence of neutropenia: • Neutrophils <1200 per microliter • Absolute Neutrophil Count (ANC) <1500 per microliter Satisfying evidence: Documentation of type OR etiology of neutropenia: • Any provider linked cause of neutropenia • Autoimmune neutropenia • Drug-induced neutropenia • Radiation neutropenia • Acquired neutropenia in newborn	✔	✔	Documentation of neutropenia (+/- lab evidence of neutropenia) without documentation of the type or etiology of neutropenia	NEUTROPENIA TYPE Please document the type or etiology of neutropenia, if known.
8007* Triggering evidence: Documentation of drug- induced neutropenia OR neutropenia secondary to chemotherapy AND No documentation of chemotherapy drug: • Methotrexate • Doxorubicin • Cytarabine • Cisplatin • Gemcitabine		✔	Notification: Documentation of drug or chemotherapy induced neutropenia
Anemia-003 Triggering evidence: Documentation of chemotherapy AND documentation of neutropenia OR lab evidence of neutropenia: • Neutrophils <1200 per microliter • ANC < 1500 per microliter Satisfying evidence: Documentation of neutropenia due to or not due to chemotherapy OR documentation of the cause or etiology of neutropenia	✔	✔	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.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
48003^L Triggering evidence: Documentation of pancytopenia (+/-) lab evidence of pancytopenia: • WBC < 4,000 • ANC < 1,500 • Platelets < 150,000 • Hemoglobin < 13 (males) • Hemoglobin < 12 (non-pregnant females) Satisfying evidence: Documentation of etiology of pancytopenia: • Any provider linked cause of pancytopenia	✔	✔	Documentation of pancytopenia (+/- lab evidence of pancytopenia) without documentation of the etiology of pancytopenia	PANCYTOPENIA ETIOLOGY Please document etiology of pancytopenia.		✔
48006^L Triggering evidence: Documentation of pancytopenia OR Laboratory evidence of pancytopenia: • WBC < 4,000 • ANC < 1,500 • Platelets < 150,000 • Hemoglobin < 13 (males) • Hemoglobin < 12 (non-pregnant females) AND MIN,1 Documentation of non-antineoplastic pancytopenia-inducing drug: • Including but not limited to: • Immunosuppresants • Anti-rheumatic agents • Immunomodulators Satisfying evidence: Documentation of non-antineoplastic induced pancytopenia : • Any provider linked non-antineoplastic drug as cause of pancytopenia OR Documentation of drug-induced pancytopenia: • Any provider linked drug as cause of pancytopenia	✔	✔	Documentation or lab evidence of pancytopenia and documentation of a non-chemotherapy pancytopenia-inducing medication without documentation of drug-induced pancytopenia	HEMATOLOGIC ABNORMALITY There is documentation or lab evidence of a hematologic abnormality and medication. Please document any link or associated diagnosis.		✔
48007^L Triggering evidence: Documentation of pancytopenia OR Laboratory evidence of pancytopenia: • WBC < 4,000 • ANC < 1,500 • Platelets < 150,000 • Hemoglobin < 13 (males) • Hemoglobin < 12 (non-pregnant females) AND Documentation of stem cell transplant OR bone marrow transplant Satisfying evidence: Documentation of pancytopenia	✔	✔	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^L Triggering evidence: Lab evidence of pancytopenia: • Age >= 19 years of age: • WBC<4,000 OR ANC <1,500 • Platelets <150,000 • Hgb <12 for non-pregnant female OR Hgb <13 for male • Age <19 years of age: • WBC<4,500 OR ANC <1,500 • Platelets <150,000 • Pediatric age based parameters for low Hgb Satisfying evidence: Documentation of pancytopenia: • Aplastic anemia • Pancytopenia • Transient erythroblastopenia • Pancytopenia caused by medication	✔	✔	Lab evidence of pancytopenia without documentation of pancytopenia	LOW WBC OR ANC, HGB, AND PLATELETS There is evidence of low WBCs or ANC, low Hgb, and low platelets. Please document any associated diagnosis.		✔
80013^A^L Triggering evidence: Lab evidence of thrombocytopenia : • Platelets < 150,000 Satisfying evidence: Documentation of thrombocytopenia OR Documentation of pancytopenia	✔	✔	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.		✔		✔
80015^A^L Triggering evidence: Lab evidence of pancytopenia: • ANC <1800/microL • Hgb <10 • Platelets <150,000 Satisfying evidence: Documentation of pancytopenia: • Pancytopenia	✔	✔	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^L Triggering evidence: Documentation of pancytopenia OR lab evidence of pancytopenia: • WBC < 4,000 • ANC < 1500 • Platelets < 150,000 • Hemoglobin < 13 (male) • Hemoglobin < 12 (female not pregnant) • Age specific lab results for pediatrics AND documentation of chemotherapy OR medication evidence of anti-neoplastic chemotherapy Satisfying evidence: Documentation of pancytopenia secondary to a specific chemotherapy agent: • Provider documented cause including, but not limited to: • Anti-neoplastic chemotherapy drugs • Chemotherapy • Reduced-intensity conditioning regimen • Myeloablative conditioning regimen	✔	✔	Documentation or lab evidence of pancytopenia and documentation or medication evidence of chemotherapy without documentation of chemotherapy-induced pancytopenia	CHEMOTHERAPY AND BLOOD DISORDER - B There is documentation or evidence of a blood disorder and chemotherapy. Please clarify whether these are causally related.		✔
PedAnemia-003^P^L Triggering evidence: Lab evidence of pancytopenia : • Age specific low WBC • Age specific low hemoglobin • Platelets less than 150,000 : • Leukocytes \| Bld-Ser-Plas : • Hemoglobin \| Bld-Ser-Plas Satisfying evidence: Documentation of pancytopenia: • Pancytopenia • Aplastic anemia • Acquired pure red cell aplasia • Fanconi's anemia	✔	✔	Pediatric: Lab evidence of pancytopenia without documentation of pancytopenia	LOW HGB, PLATELETS, AND WBC - B There is lab evidence of low hemoglobin, platelets, and white blood cell count. Please document any associated diagnosis.		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
42001 Triggering evidence: Documentation of sickle cell anemia AND MIN,2 clinical evidence of acute chest syndrome: • Body temperature >101.0 F or 38.3 C • Dementia • Brain Injury • Chest Pain NO documentation of sickle cell crisis Satisfying evidence: Documentation of acute chest syndrome	✔	✔	Documentation of sickle cell anemia and clinical evidence of acute chest syndrome without documentation of acute chest syndrome	SICKLE CELL ANEMIA There is documentation of sickle cell anemia and clinical evidence of chest pain, respiratory symptoms, exchange transfusion, or radiology findings. Please document any associated diagnosis.		✔
42002 Triggering evidence: Documentation of sickle cell anemia AND Lab or clinical evidence of splenic sequestration : • Hemoglobin < 5 • Hemoglobin decrease by 2 g/dL [requires lab documents] • Reticulocytes > 100,000 • Documentation of splenomegaly (+/- documentation of transfusion): • Blood Transfusion AND NO documentation of stem cell transplant OR NO documentation of bone marrow transplant OR NO documentation of sickle cell crisis Satisfying evidence: Documentation of splenic sequestration	✔	✔	Documentation of sickle cell anemia and lab or clinical evidence of splenic sequestration (+/- documentation of transfusion) without documentation of splenic sequestration	SICKLE CELL ANEMIA - B 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.		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
45001 Triggering evidence: Documentation of acute myeloid leukemia Satisfying evidence: Documentation of acute myeloid leukemia subtype OR grade: • Acute myeloid leukemia (AML) with minimal differentiation (FAB M0) • AML without maturation (FAB M1) • AML with maturation (FAB M2) • Acute myelomonocytic leukemia (FAB M4) • Acute monoblastic/monocytic leukemia (FAB M5) • Pure erythroid leukemia (FAB M6) • Acute megakaryoblastic leukemia (FAB M7) • Acute basophilic leukemia	✔	✔	Documentation of acute myeloid leukemia without documentation of the subtype or grade	ACUTE MYELOID LEUKEMIA - B Please document the subtype or grade of AML, if known.	✔			✔
45002 Triggering evidence: Documentation of chronic myeloid leukemia Satisfying evidence: Documentation of BCR/ABL status: • Atypical chronic myeloid leukemia • BCR/ABL negative • BCR/ABL positive • Chronic myelogenous leukemia, BCR/ABL positive	✔	✔	Documentation of chronic myeloid leukemia without documentation of BCR/ABL status	CHRONIC MYELOID LEUKEMIA Please document the CML BCR/ABL result, if known.	✔
45004 Triggering evidence: Documentation of leukemia : • Acute lymphoblastic leukemia (ALL) • Acute myeloid leukemia (AML) (+/-) Evidence of active disease : • Antineoplastic agent • Radiation • Chemotherapy • Hospice • Palliative care Satisfying evidence: Documentation of relapse, remission, not having achieved remission, OR new diagnosis of leukemia	✔	✔	Documentation of leukemia (+/- evidence of hospice, chemotherapy, radiation therapy, or antineoplastic therapy) without documentation of status (new diagnosis, never achieved remission, relapse, or remission)	LEUKEMIA Please document the leukemia status.	✔			✔
51000422 Triggering evidence: Documentation of acute lymphocytic leukemia: • Precursor B-cell lymphoblastic leukemia • Precursor T-cell lymphoblastic leukemia • Philadelphia chromosome- positive acute lymphoblastic leukemia Satisfying evidence: Docmentation of status of acute lymphocytic leukemia: • Relapse • Remission • Never achieved remission • Active • New diagnosis	✔	✔	Documentation of acute lymphocytic leukemia without documentation of status (new diagnosis, never achieved remission, relapse, or remission)	ACUTE LYMPHOCYTIC LEUKEMIA - B Please document the status of acute lymphocytic leukemia.	✔
65001 Triggering evidence: Documentation of chronic lymphocytic leukemia: • Chronic lymphocytic leukemia - B-cell type • Chronic lymphocytic leukemia - T-cell type Satisfying evidence: Documentation of status of chronic lymphocitic leukemia: • Relapse • Remission • Never achieved remission • New diagnosis	✔	✔	Documentation of chronic lymphocytic leukemia without documentation of status (new diagnosis, never achieved remission, relapse, or remission)	CHRONIC LYMPHOCYTIC LEUKEMIA Please document the status of chronic lymphocytic leukemia.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
47001 Triggering evidence: Documentation of Hodgkin lymphoma Satisfying evidence: Documentation of the subtype of Hodgkin lymphoma : • Hodgkin’s lymphoma - nodular sclerosis type • Hodgkin’s lymphoma - mixed cellularity type • Hodgkin’s lymphoma - lymphocyte rich type • Hodgkin’s lymphoma - lymphocyte depleted type • Refractory Hodgkin lymphoma	✔	✔	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 Triggering evidence: Documentation of follicular lymphoma Satisfying evidence: Documentation of grade of follicular lymphoma: • Follicular lymphoma grade I • Follicular lymphoma grade II • Follicular lymphoma grade III • Follicular lymphoma grade IIIa • Follicular lymphoma grade IIIb	✔	✔	Documentation of follicular lymphoma without documentation of grade of follicular lymphoma	FOLLICULAR LYMPHOMA Please document the grade of follicular lymphoma, if known.	✔			✔
47003 Triggering evidence: Documentation of lymphoma Satisfying evidence: Documentation of the type of lymphoma : • Including but not limited to: • B-cell lymphoma • Hodgkin's disease • Non-hodgkin's lymphoma • T-cell lymphoma	✔	✔	Documentation of lymphoma without documentation of the type of lymphoma	LYMPHOMA Please document the type of lymphoma, if known.	✔			✔
47004 Triggering evidence: Documentation of lymphoma Satisfying evidence: Documentation of the site of the lymphoma : • Any provider documented site of lymphoma	✔	✔	Documentation of lymphoma without documentation of site of lymphoma	LYMPHOMA - SITE Please document the site of lymphoma.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
60302 Triggering evidence: Documentation of metastatic disease Satisfying evidence: Documentation of the site of metastatic disease	✔	✔	Documentation of metastatic disease without documentation of the site of metastatic disease	METASTATIC DISEASE Please document the site(s) of metastatic disease.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
68001 Triggering evidence: Documentation of multiple myeloma : • Light Chain Myeloma • Non-secretory Myeloma • Immunoglobulin D (IgD) Myeloma • Immunoglobulin A (IgA) Myeloma • Plasma cell leukemia Satisfying evidence: Documentation of status of multiple myeloma: • Relapse • Remission • Never achieved remission • New diagnosis	✔	✔	Documentation of multiple myeloma without documentation of status (new diagnosis, never achieved remission, relapse or remission)	MULTIPLE MYELOMA Please document the status of multiple myeloma.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51001185 Triggering evidence: Documentation of carcinoid tumor Satisfying evidence: Documentation of the status of the carcinoid tumor: • Benign carcinoid tumor • Malignant carcinoid tumor • Metastatic carcinoid tumor	✔	✔	Documentation of carcinoid tumor without documentation of benign or malignant	CARCINOID TUMOR Please document the status of carcinoid tumor.	✔			✔
51001223 Triggering evidence: Documentation of neuroendocrine carcinoma OR neuroendocrine tumor Satisfying evidence: Documentation of neuroendocrine tumor OR carcinoma as well OR poorly differentiated OR Documentation of small OR large cell neuroendocrine carcinoma OR Documentation of neuroendocrine tumor OR carcinoma as low OR high grade	✔	✔	Documentation of neuroendocrine carcinoma or tumor without documentation of specificity (e.g., low/high grade, poorly/well differentiated, small/large cell)	NEURONDOCRINE TUMOR Neuroendocrine carcinoma or tumor has been documented. Please document specificity of carcinoma or tumor.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51001663* Triggering evidence: Documentation of cancer OR tumor: • Carcinoid tumor • Malignant neoplasm • Metastatic disease • Tumor Temporality: past OR present	✔	✔	Notification: Documentation of current or history of cancer or tumor	PRESENCE OF CANCER/TUMOR There is documentation of cancer or tumor, please ensure to specify the site and type.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
51000886 Triggering evidence: Lab evidence of positive candida auris culture: • Candida auris in unspecified specimen • Candida auris in blood, serum, plasma • Candida auris of nose • Candida auris of axilla and groin (+/-) documentation of candida auris carrier Satisfying evidence: Documentation of the presence OR absence of candida auris infection AND site	✔	✔	Lab evidence of a positive candida auris culture (+/- documentation of candida auris carrier) without documentation of the presence or absence of candida auris infection and site	UNSPECIFIED CLINICAL CONDITION - F There is lab evidence of positive candida auris culture. Please document any associated diagnosis and site.	✔	✔	✔	✔
51002203 Triggering evidence: Documentation of medication for candidiasis : • Including but not limited to: • Amphotericin B • Diflucan • Nystatin • Micafungin Satisfying evidence: Documentation of candidiasis	✔	✔	Medication evidence of candidiasis without documentation of candidiasis	FUNGAL INFECTION There is evidence of an anti-fungal medication. Please document any associated diagnosis

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
34001 Triggering evidence: Documentation of viral meningitis Satisfying evidence: Documentation of the causative organism of viral meningitis: • Including but not limited to: • Enterovirus meningitis • Herpes simplex meningitis • Meningitis caused by human cytomegalovirus • Viral meningoencephalitis • Any provider linked non-bacterial oganism as cause of viral meningitis	✔	✔	Documentation of viral meningitis without documentation of the causative organism	VIRAL MENINGITIS Please document the causative organism of viral meningitis, if known.	✔
34002 Triggering evidence: Documentation of bacterial meningitis Satisfying evidence: Documentation of bacterial meningitis causative organism: • Including but not limited to: • Gram negative bacteria meningitis • Listeria meningitis • Enterococcus meningitis • Staphylococcal meningitis • Streptococcal meningitis • Any provider linked bacterium organism as cause of bacterial meningitis	✔	✔	Documentation of bacterial meningitis without documentation of the causative organism	BACTERIAL MENINGITIS Please document the causative organism of bacterial meningitis, if known.		✔
34003 Triggering evidence: Documentation of meningitis (+/-) documentation of an organism OR the causative organism of meningitis: • Any physician documented causitive organism of meningitis Satisfying evidence: Documentation of the type of meningitis : • Aseptic meningitis • Infective meningitis • Non-pyogenic meningitis • Fungal meningitis • Chronic meningitis	✔	✔	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, if known.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
35001 Triggering evidence: Documentation of staphylococcus aureus : • Bacteremia caused by staphylococcus aureus • Infection caused by staphylococcus aureus • Methicillin resistant staphylococcus aureus positive (+/-) documentation of possible MRSA OR MSSA Satisfying evidence: Documentation of MRSA OR MSSA organism: • Methicillin resistant staphylococcus aureus • Methicillin sensitive staphylococcus aureus OR documentation of MRSA OR MSSA infection : • Community acquired methicillin resistant staphylococcus aureus • Culture positive for methicillin resistant staphylococcus aureus • Sepsis caused for methicillin resistant staphylococcus aureus	✔	✔	Documentation of Staphylococcus aureus (+/- possible MRSA or MSSA) without documentation of MSSA or MRSA infection or organism	STAPHYLOCOCCUS AUREUS There is documentation of staphylococcus aureus. Please document any associated diagnosis		✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
16003 Triggering evidence: Documentation of urosepsis (+/-) documentation of causative organism: • Aerobic bacteria • Anaerobic bacteria • Coliform bacteria • Enterococcus group • Human rhinovirus • Influenza A virus • Rickettsia • Candida (+/-) documentation of sepsis caused by organism: • Including but not limited to: • Sepsis due to aerobic bacteria • Sepsis due to anaerobic bacteria • Sepsis due to human rhinovirus • Sepsis due to candida • Any physician documented of caused by an organism Satisfying evidence: Documentation of presence or absence of sepsis due to urinary tract infection OR documentation of urinary tract infection	✔	✔	Documentation of urosepsis (+/- evidence of organism or sepsis due to an organism) without documentation of presence or absence of sepsis due to urinary tract infection or urinary tract infection	UROSEPSIS There is documentation of urosepsis. Please document a more specific diagnosis.	✔	✔	✔	✔
16006* Triggering evidence: Documentation of sepsis present on admission OR documentation of SIRS present on admission OR documentation of septic shock present on admission		✔	Notification: Documentation that sepsis, SIRS, or septic shock was present on admission
16008 Triggering evidence: Documentation of SIRS or sepsis: • Sepsis syndrome • Sepsis- associated with organ dysfunction • Septic shock • Systemic inflammatory response syndrome Satisfying evidence: Documentation of sepsis present on admission status OR documentation of the presence of sepsis on the history and physical document OR documentation of the presence of sepsis on the emergency department document OR documentation of negated sepsis on the history and physical document	✔	✔	Documentation of sepsis, SIRS, or septic shock without documentation of present on admission status	PRESENT ON ADMISSION STATUS There is documentation of SIRS or sepsis. Please document the present on admission status.		✔
16009 Triggering evidence: Documentation of sepsis due to urinary tract infection Satisfying evidence: Documentation sepsis caused by organism : • Including but not limited to: • Sepsis due to aerobic bacteria • Sepsis due to anaerobic bacteria • Sepsis due to human rhinovirus • Sepsis due to candida OR documentation of urinary tract infection site : • Cystitis • Pyelitis • Pyelonephritis • Renal candidiasis • Urethritis Documentation of hematuria	✔	✔	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^L Triggering evidence: MIN, 2 Clinical OR lab evidence of sepsis: • Including, but not limited to: • O2 sat < 85% • SBP < 90, MAP < 65 • HR > 90, RR > 20 • Lactate > 2 • Altered mental status • Hypoxia • Tachycardia • Tachypnea AND documentation of abnormal WBC count: • Bands > 10% • WBC > 12,000 • WBC < 4,000 • Pediatric ranges based on age AND documentation of abnormal temperature: • Temperature < 96.8 F or 36 C • Temperature > 101.0 F or 38.3 C (+/-) lab evidence of acute organ dysfunction : • Bilirubin > 2 • INR > than 1.5 • Platelets < 100, 000 • APTT > 60 seconds (+/-) documentation of antibiotics to treat gram negative bacteria: • Including but not limited to: • Vancomycin • Zosyn • Ciprofloxacin • Levofloxacin • Amikacin • Piperacillin (+/-) explicit mention of acute organ dysfunction: • Including but not limited to: • Myocardial infarction • Acute kidney injury • Encephalopathy • Respiratory failure (+/-) documentation of causative organism : • Including but not limited to: • Sepsis due to aerobic bacteria • Sepsis due to anaerobic bacteria • Sepsis due to human rhinovirus • Sepsis due to candida (+/-) clinical evidence of acute organ dysfunction: • Including but not limited to: • Myocardial infarction • Acute kidney injury • Encephalopathy • Respiratory failure Satisfying evidence: Documentation of sepsis, SIRS OR septic shock	✔	✔	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* Triggering evidence: Documentation of sepsis or SIRS: • Sepsis syndrome • Sepsis- associated with organ dysfunction • Septic shock • Systemic inflammatory response syndrome AND documentation of a urinary device: • Nephrostomy tube • Ureteral stent • Urinary catheter device • Catheterization of urinary bladder OR documentation of vascular device: • Cardiac valve prothesis • Central venous catheter device • Embolization coil device • Balloon pump device • Subclavian catheter • Vascular stent OR documentation of orthopedic device: • Bone plate • External fixation device • Intramedullary rod • Joint prothesis • K wire OR documentation of graft		✔	Notification: Documentation of sepsis or SIRS and documentation of a urinary device, vascular device, graft, or orthopedic device
16013* Triggering evidence: Documentation of SIRS or sepsis: • Sepsis syndrome • Septic shock • Sepsis- associated with organ dysfunction • Systemic inflammatory response syndrome (+/-) clinical evidence of sepsis : • Increased blood leukocytes • Fever • Infection in blood stream • Altered mental status • Hypotension • Acute hyperglycemia • Hypoxia (+/-) lab evidence of sepsis : • Bands > 10 • O2 sat < 85% • SBP < 90 • MAP < 65 • HR > 90 • RR > 20 • Lactate > 2 • Glucose > 120 with DM • Glucose > 140 without DM		✔	Notification: Documentation of sepsis or SIRS (+/- clinical or lab evidence of sepsis)
16015 Triggering evidence: Documentation of urinary tract infection present on admission status : • Acute cystitis • Infectious disorder of kidney • Infective cystitis • Urinary tract infection • Recurrent cystitis OR documentation of the presence of urinary tract infection on the history and physical document Satisfying evidence: Documentation of the presence or absence of a urinary device: • Nephrostomy tube • Urethral stent • Urinary catheter device • Catheterization of urinary bladder	✔	✔	Documentation of urinary tract infection as present on admission without documentation of the presence or absence of a urinary device	URINARY TRACT INFECTION POA There is documentation of a urinary tract infection present on admission, please document the presence or abscence of a urinary device.	✔
16019 Triggering evidence: Documentation of sepsis : • Sepsis syndrome • Sepsis- associated with organ dysfunction • Septic shock • Systemic inflammatory response syndrome AND NO documentation of neutropenic sepsis Satisfying evidence: Documentation of sepsis with causative organism: • Any provider linked organism as cause of sepsis OR documentation of bacteremia with causative organism: • Any provider linked organism as cause of bacteremia	✔	✔	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* Triggering evidence: Documentation of sepsis: • Sepsis syndrome • Sepsis- associated with organ dysfunction • Septic shock • Systemic inflammatory response syndrome AND documentation of transfusion of blood product		✔	Notification: Documentation of transfusion and sepsis
16021* Triggering evidence: Documentation of bacteremia		✔	Notification: Documentation of bacteremia
16022 Triggering evidence: Documentation of UTI: • Acute cystitis • Infectious disorder of kidney • Infective cystitis • Urinary tract infection Satisfying evidence: Documentation of urinary device : • Nephrostomy tube • Ureteral stent • Urinary catheter device • Catheterization of urinary bladder OR documentation of presence or absence of relationship of UTI and urinary device	✔		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 Triggering evidence: Documentation of Sepsis : • Sepsis syndrome • Sepsis- associated with organ dysfunction • Septic shock • Systemic inflammatory response syndrome AND documentation of central line: • Central venous catheter device • Tunneled central venous catheter • Subclavian catheter • Cuffed central venous catheter AND No documentation of a cause of sepsis other than central line or organisms Satisfying evidence: Documentation of sepsis due to central line OR documentation of sepsis and the presence or absence of the relationship to the central line	✔	✔	Documentation of a central line and sepsis or SIRS without documentation of sepsis and the presence or absence of the relationship to the central line	SEPSIS - CENTRAL LINE There is evidence of a central line and documentation of sepsis. Please clarify whether these are causally related.	✔			✔
16028 Triggering evidence: Documentation of sepsis: • Sepsis syndrome • Sepsis- associated with organ dysfunction • Septic shock • Systemic inflammatory response syndrome AND NO documentation of neutropenic sepsis Satisfying evidence: Documentation of cause of sepsis: • Sepsis due to organism • Sepsis due to UTI • Sepsis due to central line • Any provider linked cause of sepsis • Idiopathic sepsis • Multifactorial sepsis	✔	✔	Documentation of sepsis without documentation of the etiology of sepsis	SEPSIS - CAUSE Please document the etiology of sepsis, if known.		✔
16030 Triggering evidence: Documentation of severe sepsis Satisfying evidence: Documentation of organ dysfunction due to severe sepsis: • Acute hepatic failure due to severe sepsis • Acute renal failure due to severe sepsis • Acute respiratory failure due to severe sepsis • Acute heart failure due to severe sepsis OR documentation of any diagnosis due to severe sepsis : • Any provider linked diagnosis due to severe sepsis	✔	✔	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 Triggering evidence: Documentation of bacteremia Satisfying evidence: Documentation of presence of absence of sepsis	✔	✔	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.		✔	✔	✔
16034 Triggering evidence: Documentation of sepsis : • Sepsis syndrome • Septic shock • Sepsis- associated with organ dysfunction • Systemic inflammatory response syndrome AND NO documentation of neutropenic sepsis Satisfying evidence: Documentation of causative organism : • Any provider linked organism as cause of sepsis	✔		Documentation of sepsis without documentation of causative organism	SEPSIS Please specify causative organism of sepsis, if possible.		✔
16035^L Triggering evidence: Documentation of sepsis or SIRS: • Sepsis syndrome • Septic shock • Sepsis- associated with organ dysfunction • Systemic inflammatory response syndrome AND NO documentation of neutropenic sepsis Satisfying evidence: MIN,2 Lab evidence of sepsis: • Bands > 10% • O2 sat < 85% • SBP < 90, MAP < 65 • HR > 90 • RR > 20 • Lactate > 2 • Glucose > 120 with DM • Glucose > 140 without DM OR clinical evidence of SIRS: • Increased blood leukocytes • Fever • Infection in blood stream • Altered mental status • Hypotension • Acute hyperglycemia • Hypoxia OR lab evidence of WBC: • WBC >12,000 • WBC <4,000 • Band >10% OR vital sign evidence of temperature: • Temperature <96.8 F or 36.0 C • Temperature >101.0 F or 38.3 C (+/-) documentation of acute organ dysfunction : • Acute hepatic failure • Acute renal failure • Acute respiratory failure • Acute heart failure	✔	✔	Documentation of sepsis or SIRS without clinical or lab evidence of sepsis or SIRS	SEPSIS - CLINICAL INDICATORS SIRS/Sepsis was documented, please document supporting evidence, if known.		✔
51000001* Triggering evidence: Documentation of central line removal: • Removal of central venous line • Removal of central venous catheter • Removal of tunneled central venous catheter • Removal of peripherally inserted central catheter AND documentation of catheter tip culture		✔	Notification: Documentation of central line removal and catheter tip culture
51000323 Triggering evidence: Clinical and lab evidence of sepsis or SIRS : • WBC >12,000 or <4,000 • Temperature >100.4 F or 38 C • Temperature <96.8 F or 36 C AND MIN, 2 clinical evidence of sepsis: • Altered mental status • Hypotension • Fever • Hypoxia • Tachycardia • Tachypnea OR lab evidence of sepsis: • Bands > 10 • O2 sat < 85% • SBP < 90, MAP < 65 • HR > 90, RR > 20 • Lactate > 2 • Glucose > 120 with DM • Glucose > 140 without DM Satisfying evidence: Documentation of sepsis OR SIRS OR Septic shock	✔	✔	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* Triggering evidence: Documentation of sepsis AND NO documentation of IV fluids administration		✔	Notification: Documentation of sepsis and no documentation of IV fluid administration
51001287 Triggering evidence: Documentation of sepsis in the emergency department : • Sepsis syndrome • Septic shock • Sepsis- associated with organ dysfunction • Systemic inflammatory response syndrome Satisfying evidence: Documentation of the presence OR absence of sepsis in the inpatient documentation : • Sepsis syndrome • Septic shock • Sepsis- associated with organ dysfunction • Systemic inflammatory response syndrome	✔	✔	Documentation of sepsis in the emergency department without documentation of sepsis in the inpatient documentation	SEPSIS - B Sepsis is documented in the emergency department but has not been documented after admission. Please clarify the presence or absence of the diagnosis.		✔
51002408 Triggering evidence: Documentation of an infection: • Including but not limited to: • Abscess • Cholangitis • Pneumonia • Urinary tract infection • Colitis AND MIN,2 evidence of SIRS OR sepsis: • WBC > 12,000 or < 4,000 • Bands > 10% • Temperature < 96.8F or > 100.9F • Heart rate >90 • Respiratory rate >20 • Arterial pCO2 <32mmHg Satisfying evidence: Documentation of SIRS, sepsis OR septic shock	✔	✔	Documentation of an infection and evidence of SIRS or sepsis without documentation of SIRS, sepsis, or septic shock	INFECTIOUS DISORDER - C There is documentation of an infection and evidence of lab or vital signs abnormalities. Please document any associated diagnosis.	✔	✔	✔	✔
51002502 Triggering evidence: Documentation of SIRS, sepsis, OR septic shock: • Sepsis syndrome • Sepsis-associated organ dysfunction • Septic shock • System inflammatory response syndrome Satisfying evidence: MIN, 2 documentation of lab OR clinical evidence of SIRS OR sepsis: • Temperature > than 100.1 F or 38.3 C • Temperature < than 96.8 F or 36.0 C • Respiratory rate > than 20 • Heart rate > than 90 • WBC > 12000 or < 4000 • Bands > 10% • pCO2 arterial <32 mmHg AND documentation of a suspected or proven infection: • Including but not limited to: • Bacteremia • Cellulitis • Abscess • Peritonitis • Pneumonia OR documentation of suspected or proven non-infectious SIRS	✔	✔	Documentation of SIRS, sepsis, or septic shock without evidence of SIRS or sepsis and documentation of an infection	SEPSIS/SIRS EVIDENCE Sepsis, SIRS, or septic shock has been documented. Please include clinical indicators supporting the diagnosis of sepsis, SIRS, or septic shock.		✔
PedSepsis-003^P^L Triggering evidence: Documentation of infection: • Abcess • Cellulitis • Pneumonia • Peritonitis AND documentation of temperature: • >101.3 F or 38.5 C • <96.8 F or 36 C OR documentation of abnormal WBC count: • WBC counts based on age parameters AND MIN,2 high respiratory rate: • Elevated respiratory rate based on age parameters OR abnormal heart rate: • Abnormal heart rate based on age parameters OR clinical OR lab evidence of sepsis OR SIRS: • Temperature >101.3 F or 38.5 C • Temperature <96.8 F or 36 C • Abnormal WBC count based on age parameters (+/-) lab evidence of sepsis: • Abnormal blood gases [requires all labs to come from the same lab document] • Abnormal PTT • Abnormal platelets (+/-) documentation of organ dysfunction: • Altered mental status • AKI • Encephalopathy • DIC • Hypoxic or hypercarbic respiratory failure (+/-) clinical evidence of sepsis: • GCS <11 • Capillary refill time >3 seconds • Hypotension • Pediatric systolic hypotension (age specific) (+/-) MIN,2 medication evidence of sepsis: • Cardiac stimulant • Vasopressin OR (+/-) lab evidence of bicarbonate <8 Satisfying evidence: Documentation of the presence or absence of sepsis	✔	✔	Pediatric: Documentation of infection and clinical and lab evidence of sepsis (+/- clinical evidence of organ dysfunction or vasopressors) without documentation of sepsis or severe sepsis	INFECTION There is evidence of abnormal vital signs and/or WBC count, and documentation of an infection. Please document any associated diagnosis.		✔
Sepsis-001^L Triggering evidence: Clinical evidence of sepsis : • Temperature <96.8 F or 36.0 C • Temperature >101.0 F or 38.3 C And lab evidence of sepsis: • WBC > 12,000 or < 4,000 • Band > 10% AND MIN,2 clinical OR lab evidence of sepsis: • Bands > 10% • O2 sat < 85% • SBP < 90, MAP < 65 • HR > 90, RR > 20 • Lactate > 2 mmol/L • Glucose > 120 with DM • Glucose > 140 without DM (+/-) clinical evidence of acute organ dysfunction : • Including but not limited to: • Acute kidney injury • Encephalopathy • Respiratory failure • Hepatic failure • Blood coagulation disorder (+/-) documentation of causative organism: • Any provider linked organism as cause (+/-) documentation of acute organ dysfunction (+/-) documentation of antibiotics to treat gram negative bacteria: • Including but not limited to: • Vancomycin • Zosyn • Ciprofloxacin • Levofloxacin • Amikacin • Piperacillin (+/-) evidence of vasopressors : • Epinephrine • Vasopressin • Norepinephrine • Dobutamine Satisfying evidence: Documentation of sepsis, SIRS OR septic shock	✔	✔	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^L Triggering evidence: Documentation of infection : • Including but not limited to: • Abscess • Cellulitis • Cystitis • Bacteremia • Peritonitis • Cholangitis AND clinical evidence of sepsis : • Temperature <96.5 F or 35.8 C • Temperature >100.9 F or 38.22 C AND lab evidence of sepsis: • Band > 10% • WBC > 12,000 or < 4,000 AND MIN,2 clinical evidence of sepsis : • Altered mental status • Acute hyperglycemia • Fever • Hypotension • Hypoxia OR lab evidence of sepsis: • Band > 10% • WBC > 12,000 or < 4,000 • Lactate >2 • O2 saturation <85% • Respiratory rate >22 • Heart rate >90 • SBP <90 mmHg or MAP <65 mmHg • Glucose >120 with DM (+/-) evidence of antibiotics administered : • Vancomycin • Gentamycin • Piperacillin • Tazobactam • Meropenem (+/-) documentation of causative organism : • Any provider linked organism as cause (+/-) documentation of antibiotics to treat gram negative bacteria: • Including but not limited to: • Vancomycin • Zosyn • Ciprofloxacin • Levofloxacin • Amikacin • Piperacillin (+/-) documentation OR evidence of acute organ dysfunction : • Including but not limited to: • Acute kidney injury • Encephalopathy • Respiratory failure • Hepatic failure • Blood coagulation disorder Satisfying evidence: Documentation of sepsis, SIRS or septic shock	✔	✔	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 Triggering evidence: Documentation of burn sepsis Satisfying evidence: Documentation of localized infection OR systemic sepsis	✔	✔	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 Triggering evidence: Documentation of sepsis : • Temperature > than 100.1 F or 38.3 C • Herat rate > than 110 • WBC > 12000 • Bands > 10% AND MIN, 3 lab OR clinical evidence of sepsis: • Temperature > than 100.1 F or 38.3 C • Herat rate > than 110 • WBC > 12000 or < 4000 • Bands > 10% Satisfying evidence: Documentation of sepsis present on admission status OR documentation of sepsis present of admission status in the history and physical document OR documentation of sepsis present of admission status in the emergency department document	✔	✔	Documentation of sepsis and clinical or lab evidence of sepsis without documentation of present on admission status (age: >= 18 years)	PSI 13 SEPSIS Please document whether sepsis was present on admission.		✔
Sepsis-007 Triggering evidence: Documentation of sepsis due urinary tract infection Satisfying evidence: Documentation of urinary tract infection site: • Cystitis • Pyelitis • Urethritis • Pyelonephritis • Renal candidiasis AND Documentation of causative organism: • Including but not limited to: • Aerobic bacteria • Anaerobic bacteria • Coliform bacteria • Enterococcus group • Candida	✔	✔	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-008^A^L Triggering evidence: Documentation of infection : • Including but not limited to: • Bacteremia • Cellulitis • Abscess • Peritonitis • Pneumonia AND MIN,2 documentation of lab OR clinical evidence of sepsis: • Temperature > than 100.1 F or 38.3 C • Temperature < than 96.8 F or 36.0 C • Respiratory rate > than 20 • Heart rate > than 95 • WBC > 12000 or < 4000 • Bands > 10% • PaCO2 <32 (+/-) documentation of acute organ dysfunction : • Bilirubin > than 2 mg/dl • Systolic blood pressure < than 90 mmHg • MAP < that 65 mmHg • Platelets < than 100, 000 • Lactate > than 2 mmol/L • Creatinine > than 2 without renal failure • INR > than 1.5 without anticoagulant • aPTT > than 60 seconds without anticoagulant • Altered mental status • Encephalopathy Satisfying evidence: Documentation of sepsis, SIRS OR severe sepsis	✔	✔	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 Triggering evidence: Documentation of sepsis : • Sepsis syndrome • Sepsis-associated organ dysfunction • Septic shock • System inflammatory response syndrome AND NO documentation of neutropenic sepsis AND NO documentation of neonatal sepsis Satisfying evidence: Documentation of sepsis with a causative organism OR documentation of bacteremia with a causative organism	✔	✔	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.	✔	✔		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
Sepsis-006 Triggering evidence: MIN, 2 Documentation of lab OR clinical evidence of SIRS: • Procalcitonin >= 0.25 ng/mL • Glucose >140 mg/dl without DM • C reactive protein >= 1 md/dl AND documentation of major surgery: • Open reduction internal fixation • Craniotomy • Laceration repair • Grafting procedure • Exploration or skin wound or burn OR documentation of major trauma: • Including but not limited to: • Crushing injury • Assault • Gunshot wound • MVA • Multiple injury OR documentation of burn: • Thermal burn • Chemical burn • Burn • Electrical burn • Radiation burn OR documentation of pancreatitis (+/-) lab OR clinical evidence of noninfectious SIRS: • Procalcitonin >= 0.25 ng/mL • Glucose >140 mg/dl without DM • C reactive protein >= 1 md/dl Satisfying evidence: Documentation of the presence OR absence of non-infectious SIRS	✔	✔	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 documentation of trauma, burn, pancreatitis, or surgery and abnormal clinical and lab evidence findings. Please document any associated diagnosis.		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12002 Triggering evidence: Documentation of altered mental status: • Altered mental status • Decreased level of consciousness • Clouded consciousness OR documentation of unresponsiveness: • Coma • Dementia • Vegetative state • Unconscious • Unresponsive Satisfying evidence: Documentation of etiology: • Encephalopathy • Seizure disorder • Overdose • Stroke • Cerebral ischemia • Idiopathic etiology • Multifactorial etiology • Any physician linked etiology	✔	✔	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 Triggering evidence: MIN 2, Documentation of unresponsiveness: • Unconscious • Unresponsive • Disturbance of consciousness Satisfying evidence: Documentation of level of unresponsiveness: • Vegetative state • Coma • Dementia • Psychotic disorder • Obtundation	✔	✔	Documentation of unresponsiveness without documentation of the level of unresponsiveness	LEVEL OF UNRESPONSIVENESS Please document the level of unresponsiveness.
12021 Triggering evidence: MIN 2, Documentation of altered mental status Satisfying evidence: Documentation of specificity of altered mental status : • Vegetative state • Dementia • Delirium • Obtundation • Psychotic disorder AND documentation of etiology of altered mental status: • Cerebrovascular accident • Seizure disorder • Any physician linked cause of altered mental status • Idiopathic altered mental status • Multifactorial altered mental status	✔	✔	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.	✔	✔	✔	✔
150003 Triggering evidence: MIN,2 Documentation of altered mental status: • Decreased level of consciousness • Altered mental status • Clouded consciousness Satisfying evidence: Documentation of level of altered mental status: • Including but not limited to: • Vegetative state • Coma • Psychotic disorder • Obtundation	✔	✔	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.		✔	✔	✔
AltMentalStatus-001 Triggering evidence: Documentation of AMS: • Altered mental status • Clouded consciousness • Decreased level of consciousness OR Documentation of unresponsiveness: • Coma • Delirium • Persistent vegatative state OR Documentation of encephalopathy: • Encephalopathy • Anoxic encephalopathy • Drug-induced encephalopathy • Hepatic encephalopathy • Ischemic encephalopathy Satisfying evidence: Documentation of the type of encephalopathy: • Chronic traumatic encephalopathy • Hypertensive encephalopathy • Multifactorial encephalopathy • Toxic encephalopathy • Uremic encephalopathy OR Documentation of the level of unresponsiveness: • Coma • Locked in syndrome • Persistent vegatative state OR Documentation of the level of altered mental status: • Delirium • Dementia • Stupor	✔	✔	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, unresponsiveness or type of encephalopathy.	✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
12027 Triggering evidence: Documentation of cognitive disorder : • Cognitive disorder • Neurocognitive disorder Satisfying evidence: Documentation of the type of cognitive disorder : • Dementia • Delirium • Amnesia	✔	✔	Documentation of a cognitive disorder without documentation of the type of cognitive disorder	COGNITIVE DISORDER Please document type of cognitive disorder.	✔		✔	✔
12028 Triggering evidence: Documentation of cognitive disorder: • Cognitive disorder • Neurocognitive disorder Satisfying evidence: Documentation of the etiology of cognitive disorder: • Depression • Encephalitis • Alcohol abuse • Intracranial tumor • Sepsis • Idiopathic cognitive disorder • Multifactorial cognitive disorder • Any physician linked etiology of cognitive disorder	✔	✔	Documentation of a cognitive disorder without documentation of the etiology of the cognitive disorder	COGNITIVE DISORDER - ETIOLOGY Please document etiology of cognitive disorder.	✔		✔	✔
5060007 Triggering evidence: Documentation of eating disorder Satisfying evidence: Documentation of the type of eating disorder: • Anorexia nervosa • Bulimia nervosa • Purging • Pica • Binge eating disorder • Weight fixation	✔	✔	Documentation of an eating disorder without documentation of the type of eating disorder	EATING DISORDER Please document the type of eating disorder.	✔			✔
5060008 Triggering evidence: Documentation of bipolar disorder: • Bipolar disorder Satisfying evidence: Documentation of the type of bipolar disorder : • Including but not limited to: • Bipolar I • Bipolar II • Mixed bipolar • Depressed bipolar • Manic bipolar • Schizoaffective bipolar AND documentation of the severity of bipolar disorder: • Including but not limited to: • Mild bipolar disorder • Moderate bipolar disorder • Severe bipolar disorder	✔	✔	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 Triggering evidence: Documentation of anxiety disorder: • Including but not limited to: • Anxiety disorder • Phobic disorder • Panic disorder • Anxiety with depression • PTSD Satisfying evidence: Documentation of the type of anxiety disorder : • Including but not limited to: • Generalized anxiety disorder • Phobic disorder • Panic disorder • Psycoactive substance-induced organic anxiety • PTSD AND documentation of acuity of anxiety disorder: • Acute • Chronic • Acute on chronic	✔	✔	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.				✔
5060014* Triggering evidence: MIN,3 Documentation of antipsychotic medications	✔	✔	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 Triggering evidence: Documentation of suicidal ideation OR history of suicidal ideation Satisfying evidence: Documentation of the length of time of suicidal ideation	✔	✔	Documentation of suicidal ideation or history of suicidal ideation without documentation of length of time of the suicidal ideation	SUICIDAL IDEATION There is documentation of or history of suicidal ideation. Please document the length of time of suicidal ideation, if known.	✔
5060021 Triggering evidence: Documentation of dementia (+/-) evidence of behavioral disturbance: • Including but not limited to: • Aggressive behavior • Delusions • Disoriented • Hallucinations • Stupor Satisfying evidence: Documentation of the type of dementia: • Including but not limited to: • Primary degenerative dementia • Alzheimer's disease • Senile dementia • Vascular dementia • Lewy body dementia	✔	✔	Documentation of dementia (+/- documentation of behavioral disturbance) without documentation of the type of dementia	DEMENTIA Please document the type of dementia.	✔			✔
51000462 Triggering evidence: Documentation of vascular dementia Satisfying evidence: Documentation of the type of vascular dementia: • Multi-infarct dementia • Acute vascular dementia • Arteriosclerotic dementia • Ischemic vascular dementia • Subcortical vascular dementia	✔	✔	Documentation of vascular dementia without documentation of type of vascular dementia	VASCULAR DEMENTIA Please document the type of vascular dementia.	✔
51001623 Triggering evidence: Documentation of vascular dementia Satisfying evidence: Documentation of the etiology of vascular dementia: • Any physician linked cause of vascular dementia • Idiopathic vascular dementia • Multifactorial vascular dementia	✔	✔	Documentation of vascular dementia without documentation of the etiology of the vascular dementia	BEHAVIORAL HEALTH Please document the etiology of the vascular dementia
51002742 Triggering evidence: Documentation of dementia OR cognitive impairment (+/-) medication evidence of behavioral disturbance: • Antipsychotics OR clinical evidence of behavioral disturbance: • Bedside sitter • Aggressive behavior • Combativeness • Delirium • Sundowning • Restraints Satisfying evidence: Documentation of presence or absence of behavioral disturbance: • Aggressive behavior • Behavioral disturbance • Dementia with psychotic disturbance • Disturbance in mood	✔	✔	Documentation of dementia or cognitive impairment (+/- evidence of dementia) without documentation of presence or absence of behavioral disturbance	DEMENTIA - A There is documentation of dementia. Please document any associated diagnosis.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
40600^P Triggering evidence: Documentation of developmental delay OR global developmental delay Satisfying evidence: Documentation of a specific developmental delay: • Including but not limited to: • Speech Disorder • Developmental Disorder • Learning difficulties • Pervasive developmental disorder	✔	✔	Pediatric: Documentation of a developmental delay without documentation of the type of development delay	DEVELOPMENTAL DELAY Please document the type of developmental delay.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
40300 Triggering evidence: Documentation of intellectual disability Satisfying evidence: Documentation of severity of intellectual disability: • Mild • Moderate • Severe • Profound	✔	✔	Documentation of an intellectual disability without documentation of the severity of intellectual disability	INTELLECTUAL DISABILITY Please document the severity of intellectual disability.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
5060004* Triggering evidence: Documentation of clinical depression: • Depression • Depressive disorder • Depressive episode	✔	✔	Mention of clinical depression is present	FOLLOW-UP PLAN Clinical depression has been documented. Please consider a follow-up plan.
5060011 Triggering evidence: Documentation of depression Satisfying evidence: Documentation of the type of depression: • Including but not limited to: • Atypical depressive disorder • Bipolar with most recent episode depressive • Drug-induced depressive state • Major depressive disorder • Postpartum depression AND documentation of acuity of depression: • Acute • Chronic • Acute on chronic AND documentation of the occurrence of depression : • Most recent episode • Single episode	✔	✔	Documentation of depression without documentation of the acuity, occurrence, and type of depression	DEPRESSION Please document the type, acuity and occurrence of depression.	✔		✔	✔
5060016 Triggering evidence: Documentation of depression OR Documentation of past depression AND Documentation of active medications treating depression: • Antidepressant • Monoamine oxidase inhibitor • Norepinephrine reuptake inhibitor Satisfying evidence: Documentation of episode of depression : • Single • Recurrent AND Documentation of severity of depression : • Mild depressive disorder • Moderate depressive disorder • Severe depressive disorder AND Documentation of status of depression: • Partial remission • Full remission	✔	✔	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.	✔		✔	✔
51001302^A Triggering evidence: Documentation of antidepressant treatment : • Antidepressant • Monoamine oxidase inhibitor • Norepinephrine reuptake inhibitor (+/-) Documentation of severity OR episode of depression: • Mild depression • Moderate depression • Severe depression • Single epsiode • Recurrent Satisfying evidence: Documentation of depression OR depressive disorder: • Agitated depression • Anxiety and depression • Bi polar depression	✔	✔	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.
51001962 Triggering evidence: Documentation of depression OR Documentation of history of depression (+/-) Documentation of anti-depressant medication: • Selective serotonin reuptake inhibitors • Monoamine oxidase inhibitors • Norepinephrine reuptake inhibitors • Tricyclic antidepressants • Satisfying evidence: Documentation of type of depression: • Bipolar disorder • Postpartum depression • Major depressive disorder • Drug-induced depressive state	✔	✔	Documentation of depression or history of depression (+/- documentation of anti-depressant medication) without documentation of type of depression	DEPRESSION TYPE There is documentation of depression, please document the type.	✔		✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
5060009 Triggering evidence: Documentation of schizophrenia: • Schizoaffective schizophrenia • Schizophrenia (+/-) Evidence of schizophrenia: • Including but not limited to: • Catatonic reaction • Paranoid • Delusions • Lack of emotional response • Hallucinations Satisfying evidence: Documentation of the type of schizophrenia: • Type 1 schizophrenia • Type 2 schizophrenia • Combined schizophrenia	✔	✔	Documentation of schizophrenia (+/- evidence of schizophrenia) without documentation of the type of schizophrenia	SCHIZOPHRENIA Please document the type of schizophrenia.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
5060018 Triggering evidence: Documentation of alcohol abuse AND Documentation of CIWA (+/-) Medication evidence of IV Lorazepam Satisfying evidence: Documentation of alcohol dependence AND Documentation of alcohol withdrawal OR alcohol withdrawal syndrome	✔	✔	Documentation of CIWA and alcohol abuse (+/- medication evidence of IV Lorazepam) without documentation of alcohol dependence and withdrawal	ALCOHOL ABUSE There is documentation of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) and documentation of alcohol abuse. Please document any other associated conditions.	✔
5060019 Triggering evidence: Documentation of alcohol withdrawal Satisfying evidence: Documentation of alcohol dependence OR Documentation of alcohol abuse OR Documentation of severe alcohol use disorder	✔	✔	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.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
5060017 Triggering evidence: Documentation of a nicotine patch Satisfying evidence: Documentation of nicotine dependence AND Documentation of nicotine withdrawal	✔	✔	Documentation of a nicotine patch without documentation of nicotine dependence and withdrawal	NICOTINE PATCH Please consider documenting if nicotine dependence and withdrawal are present.	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
5060020 Triggering evidence: Documentation of substance abuse Satisfying evidence: Documentation of type of dependency: • Physical addiction • Unknown dependence • Psychological addiction AND Documentation of status of substance abuse: • Current • Prior • Stopped AND Documentation of drug type: • Including but not limited to: • Polysubstance • Hallucinogenic agent • Opioid • Cocaine • Heroin • Opium • Central nervous system agent	✔	✔	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.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
14006 Triggering evidence: Documentation of an open fracture of a long bone: • Open fracture of femur • Open fracture of tibia • Open fracture of fibula • Open fracture of radius • Open fracture of ulna • Open fracture of humerus Satisfying evidence: Documentation of stage of Gustilo classification: • Type 1 • Type 2 • Type 3 • Type 3A • Type 3B • Type 3C	✔	✔	Documentation of an open fracture of a long bone without documentation of Gustilo classification	GUSTILO CLASSIFICATION There is documentation of an open fracture of a long bone. Please document the classification.	✔	✔		✔
14007 Triggering evidence: Documentation of fracture Satisfying evidence: Documentation of fracture with laterality: • Right • Left • Bilateral	✔	✔	Documentation of fracture without documentation of the laterality of the fracture	FRACTURE LATERALITY Please document the laterality of the fracture.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
20008 Triggering evidence: Documentation of laceration OR wound: • Superficial laceration • Major open wound • Simple laceration • Stab wound • Open laceration AND Documentation of repair OR closure (+/-) evidence of complexity Satisfying evidence: Documentation of complexity of repair : • Simple closure • Complex closure • Simple repair • Complex repair • Superficial laceration AND Documentation of wound measurement	✔	✔	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.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
20018 Triggering evidence: Documentation of burn Satisfying evidence: Documentation of burn with depth (degree): • Superficial • Partial-thickness • Full-thickness AND documentation of burn with laterality: • Right • Left • Bilateral AND documentation of burn agent: • Including but not limited to: • Electrical • Chemical • Cold • Radiation • Thermal • UV light AND documentation of burn with site: • Any provider linked site of the burn AND documentation of body surface area AND documentation of burn present on admission status OR documentation of the presence of burn on the history and physical document OR documentation of negated burn on the the history and physical document	✔	✔	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 present on admission status of the burn.	✔	✔	✔	✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
28000 Triggering evidence: MIN 3, Evidence of functional quadriplegia OR quadriparesis: • Immobile • Incontinence • Feeding Tube • Total self-care deficit • Unresponsive AND NO documentation of ambulation OR cervical spinal cord injury quadriplegia Satisfying evidence: Documentation of functional quadriplegia OR quadriparesis	✔	✔	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 any associated diagnosis.		✔	✔	✔
28001 Triggering evidence: Documentation of functional quadriplegia OR quadriparesis AND NO documentation of cervical spinal cord injury Satisfying evidence: Documentation of the etiology of functional quadriplegia OR quadriparesis: • Dementia • Brain Injury • Cerebrovascular accident • Any physician linked cause of functional quadriplegia or quadriparesis • Idiopathic functional quadriplegia or quadriparesis • Multifactorial functional quadriplegia or quadriparesis	✔	✔	Documentation of functional quadriplegia or quadriparesis without documentation of the etiology of functional quadriplegia or quadriparesis	FUNCTIONAL QUADRIPLEGIA Please document the etiology of the functional quadriplegia or quadriparesis.		✔
28003 Triggering evidence: Documentation of functional quadriplegia OR quadriparesis : • Functional quadriplegia • Functional quadriparesis AND NO documentation of cervical spinal cord injury quadriplegia Satisfying evidence: Documentation of clinical evidence of functional quadriplegia OR quadriparesis : • Immobile • Bed-ridden • Incontinence • Total self-care deficit • Traumatic brain injury (TBI)	✔	✔	Documentation of functional quadriplegia or quadriparesis without evidence of functional quadriplegia or quadriparesis	FUNCTIONAL QUADRIPLEGIA - B There is documentation of functional quadriplegia or quadriparesis. Please document any clinical evidence associated with quadriplegia or quadriparesis.		✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
2004003 Triggering evidence: Documentation of hospice OR palliative care qualifiers: • End of life care • Terminal care • Dying care • Comfort measures • Poor prognosis NOT end stage renal failure: • • • Satisfying evidence: Documentation of hospice OR palliative care: • Hospice care • Admission to hospice • Palliative care	✔	✔	Documentation of hospice or palliative care qualifiers without documentation of hospice or palliative care	HOSPICE OR PALLIATIVE CARE There is documentation of hospice or palliative care qualifiers. Please document hoscpice or palliative care properly.
51001842 Triggering evidence: Documentaton of hospice care qualifiers: • Terminal care • Dying care • Comfort care • Moribund NOT Documentation of end stage renal disease Satisfying evidence: Documentaton of of the presence or absence of hospice care: • Hospice care • Admission to hospice • Terminal illness	✔	✔	Documentation of hospice care qualifiers without documentation of the presence or absence of hospice care	HOSPICE CARE Please document presence or absence of hospice care.
51001943 Triggering evidence: Documentation of palliative care qualifiers: • Complex care needs • Continuous home oxygen • Decline in functional status • Lives in a nursing home • Rapidly progressive dementia • Total self-care deficit Satisfying evidence: Documentation of the presence or absence of palliative care: • Admission to palliative care • Palliative care • Under care of palliative care physician	✔	✔	Documentation of palliative care qualifiers without documentation of the presence or absence of palliative care	PALLIATIVE CARE There is documentation of palliative care qualifiers. Please document presence or absence of palliative care.

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
58001 Triggering evidence: MIN 2 Documentation of HIV positive: • Acute human immunodeficiency virus infection • Human immunodeficiency virus enzyme-linked immunosorbent • Human immunodeficiency virus infection • Human immunodeficiency virus positive AND (+/-) Lab evidence of CD4 percentage OR HIV viral load OR CD4 count (+/-) Documentation of HIV-related condition: • HIV dementia • Coccidioidomycosis • Recurrent pneumonia • Cytomegalovirus infection • Cryptococcosis (+/-) Documentation of HIV medication: • Antiretrovirals • Anti-HIV agent-protease inhibitor • Anti-HIV agents Satisfying evidence: Documentation of symptomatic OR asymptomatic OR AIDS OR unable to determine HIV status: • Acquired immune deficiency syndrome • Asymptomatic human immunodeficiency virus infection • Symptomatic human immunodeficiency virus infection • Unknown HIV status	✔	✔	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 Please document the status of HIV.	✔			✔

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
27000* Triggering evidence: Documentation of an MCC medical condition OR documentation of CC medical condition		✔	Notification: Documentation of an MCC or CC medical condition

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
3000601*			There is evidence of HAC 01 (Foreign object retained after surgery)
3000602*			There is evidence of HAC 02 (Air embolism)
3000603*			There is evidence of HAC 03 (Blood incompatibility)
3000604*			There is evidence of HAC 04 (Stage 3 and 4 pressure ulcers)
3000605*			There is evidence of HAC 05 (Falls and trauma)
3000606*			There is evidence of HAC 06 (Catheter-associated UTI)
3000607*			There is evidence of HAC 07 (Vascular catheter-associated infection)
3000608*			There is evidence of HAC 08 (Surgical site infection- mediastinitis after coronary bypass graft)
3000609*			There is evidence of HAC 09 (Manifestations of poor glycemic control)
3000610*			There is evidence of HAC 10 (DVT/PE with total knee or hip replacement)
3000611*			There is evidence of HAC 11 (Surgical site infection -bariatric surgery)
3000612*			There is evidence of HAC 12 (Surgical site infection after procedures of spine, shoulder and elbow)
3000613*			There is evidence of HAC 13 (Surgical site infection after cardiac electronic device procedures)
3000614*			There is evidence of HAC 14 (Iatrogenic pneumothorax with venous catheterization)

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
3000001*			There is evidence of PSI 03 (Pressure Ulcer)
3000002*			There is evidence of PSI 06 (Iatrogenic (post-procedural) pneumothorax)
3000003*			There is evidence of PSI 08 (In hospital fall with hip fracture)
3000004*			There is evidence of PSI 09 (Perioperative hemorrhage or postoperative hematoma)
3000005*			There is evidence of PSI 10 (Postoperative acute kidney injury requiring dialysis)
3000006*			There is evidence of PSI 11 (Postoperative respiratory failure)
3000007*			There is evidence of PSI 12 (Perioperative pulmonary embolism or deep vein thrombosis)
3000008*			There is evidence of PSI 13 (Postoperative sepsis)
3000009*			There is evidence of PSI 14 (Postoperative Wound Dehiscence Rate)
3000010*			There is evidence of PSI 15 (Unrecognized abdomino-pelvic accidental puncture or laceration rate)

Opportunities

¹Engage One  ²CDI Collaborate and 360 Encompass Evidence Sheets
^AAdult Only  ^PPediatric Only
^LLab Feed Required  ^RRadiology Feed Required
^SSingle Document Processing
*Clinical Notification
Code	Product		Description	Physician Message	Risk Classification
Code	E1¹	CDI²	Description	Physician Message	CC	MCC	HCC	MS-DRG
40700 Triggering evidence: Evidence of medical non-compliance: • Consent for operation refused • Did not attend- hospital appointment • Did not attend- no reason • Did not wait for treatment • Left AMA • Patient defaulted from follow-up OR refused procedure Satisfying evidence: Documentation of medical non-compliance: • Drug compliance poor • Left AMA • Non-compliance of drug therapy • Non-compliant • Noncompliance with treatment • Poor compliance with inhaler	✔	✔	Evidence of medical non-compliance without documentation of medical non-compliance	MEDICAL COMPLIANCE STATUS Please document the medical compliance status.			✔
51000763* Triggering evidence: Documentation of specimen sent		✔	Notification: Documentation in a surgical note of a specimen sent for analysis
SpecialReqWMC-002* Triggering evidence: Documentation of 'In the setting of’		✔	Notification: Documentation of 'in the setting of'