Brandon Losacker • November 13, 2024
CDI Tips: Key Indicators for Documenting Transient Tachypnea of the Newborn (TTN) – Quick Guidance for Accurate Diagnosis and Coding"
Transient Tachypnea of the Newborn (TTN)
TTN: a parenchymal lung disorder characterized by pulmonary edema resulting from delayed resorption and clearance of fetal alveolar fluid. It is the most common cause of respiratory distress in late preterm and term infants and is generally a benign, self-limited condition.
Clinical Manifestations of TTN
· Onset usually between the time of birth and two hours after delivery
· Tachypnea – most common feature with respiratory rate > 60 breaths per minute
· Infants with more severe disease may exhibit:
- Cyanosis
Increased work of breathing which includes:
- Nasal flaring
- Mild intercostal and subcostal retractions
- Expiratory grunting
· Anterior-posterior diameter of the chest may be increased
· Typically with clear lungs (no rales/rhonchi)
· Mild to moderate TTN are symptomatic for 12-24 hours but signs may persist as long as 72 hours in more severe cases
· Characteristic radiographic features:
o CXR – increased lung volumes with flat diaphragms, mild cardiomegaly, prominent vascular markings in a sunburst pattern originating at the hilum, fluid in the interlobar fissures, pleural effusions, alveolar edema appearing as fluffy densities. There are no areas of alveolar densities or consolidation
o Lung US – pulmonary edema, compact B lines, double lung point, regular pleural line without consolidation
TTN is a benign disorder and pathologic conditions that also present with respiratory distress must be excluded.
- Pneumonia – chest radiography differentiates PNA from TTN as neonatal PNA is characterized by alveolar densities with air bronchograms or patchy infiltrates, not seen in TTN.
- Sepsis – infants with sepsis and respiratory distress are differentiated from those with TTN with the persistence of additional symptoms and the lack of the characteristic chest radiographic findings of TTN.
- Congenital cardiac disease - TTN is distinguished from congenital heart disease by physical findings (e.g., heart murmur, abnormal precordial activity), chest radiography, pre- and post-ductal pulse oximetry, and echocardiography.
Respiratory distress syndrome – differentiated from TTN with a characteristic chest radiograph of a ground glass appearance with air bronchograms. Caused by surfactant deficiency most common in very preterm infants.
Code for Transient tachypnea of newborn (TTN) falls under ICD-10 Chapter 16 – Certain conditions originating in the perinatal period [P00-P96]
· P19-P29 – Respiratory and cardiovascular disorders specific to the perinatal period
· P22 - Respiratory distress of newborn
· P22.0 – Respiratory distress syndrome of newborn
· P22.1 – Transient tachypnea of newborn
· P22.8 – Other respiratory distress of newborn
· P22.9 – Respiratory distress of newborn, unspecified
Additional Tips:
· TTN is also documented as Respiratory distress syndrome Type II, Wet lung syndrome
· Tachypnea alone is just a symptom
· Most common risk factors for TTN include prematurity, Cesarean delivery, maternal diabetes, maternal obesity, maternal asthma
· Infants with TTN rarely require a fraction of inspired oxygen (FiO2) >0.4.
References
Johnson, K. E. (2021, August 30). Transient tachypnea of the newborn. UpToDate. www.uptodate.com/contents/transient-tachypnea-of-the-newborn
“Respiratory Conditions Neonatal.” Pro ACDIS Pocket Resource Online, pro.acdis.org/inpatient/conditions/respiratory-conditions-neonatal. Accessed 4 Dec. 2023.
Can Providers Truly Win?
This is a short synopsis of a possible patient record and is not intended to be all-inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.
Common definitions for this discussion: Adverse Effect: occurs when a substance is taken according to direction and a reaction occurs Poisoning: indicates improper use of medication including combination with alcohol, overdose, wrong drug, wrong dose, or taken in error Underdosing refers to taking less or discontinuing a medication that is prescribed Toxic Effects: a reaction, consequence, or effect of a non-medicinal substance such as alcohol, animal venom, or carbon monoxide Provider documentation needs to be clear whether a drug was taken as directed or improperly administered to determine an adverse effect vs. poisoning. For example, a patient with a GI bleed due to Coumadin therapy would need clarification if the Coumadin was taken properly or not taken properly. Taken properly as directed would have an adverse effect – Principal diagnosis is the nature of the adverse effect. GI bleed is associated with Coumadin therapy, taken properly. Taken improperly would be poisoning – The principal diagnosis is the poisoning effect from improper coumadin. GI bleeding is associated with Coumadin therapy, not taken properly Provider documentation should be clear whether a diagnosis results from a cause/effect of poisoning. For example, a patient admitted/discharged with a diagnosis of musculoskeletal chest pain with cocaine use just before the onset of symptoms. Chest pain associated with cocaine use provides clarity on the etiology of the pain. Poisoning is the principal diagnosis, and chest pain is the secondary diagnosis. Provider documentation must be clear whether a diagnosis results from a toxic effect. For example, a patient is admitted with right hand cellulitis and documentation in the nurse’s notes reflects patient was bitten by a spider on the right hand the day before admission. Right-hand cellulitis due to spider bite provides clarity of the cause of the cellulitis. A toxic effect diagnosis would be the principal diagnosis and cellulitis would be a secondary diagnosis. Codes for underdosing should never be assigned as principal diagnosis or first listed codes. The exacerbation or relapse of a medical condition due to under dosing is the principal diagnosis. For example, seizure disorder will be principal when a patient is admitted after having a seizure and noted with subtherapeutic Dilantin levels. Additional Tips: Use as many codes as necessary to describe completely all manifestation of the adverse effect, poisoning, underdosing, or toxic effect. If two or more drugs, medicinal or biological substances are taken, code each individually The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined). If the intent of the poisoning is unknown or unspecified, code the intent as accidental intent. The undetermined intent is only for use if the documentation in the record specifies that the intent cannot be determined. Documentation of a change in the patient’s condition is not required in order to assign an underdosing code. Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded too. If marijuana is legalized for therapeutic/recreational use per state legislature (depending on the documentation in the chart), it is no longer considered an illicit drug. To capture an adverse reaction in this case, it would be coded as poisoning or adverse effect.
It’s not new news that work as we knew it has changed dramatically over the past few years with more employees working remotely than ever before. While this is a newer phenomenon for many HIM employees, at UASI we’ve been working this way for over 20 years. In order to recruit and retain the best in the field, and cut down on travel hassle for our teams and costs for our clients, we built our remote coding services practice 23 years ago. Our success operating this way led us to quickly adopt remote working for our Revenue Integrity, CDI, Audit and Coding Review and consulting teams as well. This has enabled us to find the best talent no matter which zip code he/she lives in over the years. Working remotely can be lonely and people can feel isolated, so it’s important to engage your staff regularly and in various ways. Though there are countless articles and blog posts about working remotely successfully, it’s still a struggle for many. Regardless of having 20+ years of experience operating this way, it never hurts to remind ourselves what works, so we wanted to share a few tips. Routinely schedule calls with your team members to check in and see how they personally are doing and how the work is going. Make sure to personalize the call and ask if goals are being met and if there are issues preventing their success or milestones to celebrate. Send emails consistently that not only check in on people, but also share something fun and/or educational such as: Industry hot topics and/or education Fun facts for that month or week Celebrations such as birthdays, births, graduations, work anniversaries Congratulations on obtaining new credentials or a personal milestone Make Department meetings fun and educational. After providing an overview of the team performance and updates, ask a few people to share something about themselves and/or have a few team members take turns presenting an educational topic briefly. This enables them to work together on something, work on something different than their day-to-day responsibilities and educate the team at the same time. You can even play online games to get to know each other or just to have fun. Our teams play trivia games, bingo, and even industry-related word searches. It is a simple way to engage people and creates opportunities to bond with one another. Share good news with the team when someone is successful or gets a compliment from a client. This way the whole team can share in the success and appreciate the fact that they are working with smart, successful teammates. You can even set up a system to allow staff to nominate each other for great work or achievements for anyone in the company. At UASI, we have our Values-In-Action program where our associates nominate one another for demonstrating our values. It brings energy to our day when those nominations get recognized and reinforces the values of the organization at the same time. It’s not only a proud moment for a person when he/she is recognized, but those nominating get satisfaction from it as well. Conduct remote social activities. Some successes we’ve had are creating a social media “breakroom” for staff only, creating holiday cookbooks or even gift exchanges where you can celebrate together virtually. Remote gift exchanges do take a little coordination, but how fun is it to get a “surprise” in the mail? Invite individuals to participate in health-related challenges, such as step challenges, mindfulness meditation or some type of self-care. These are important because let’s face it, we sit all day. If we can help our teams stay active, they will be healthier and happier. At UASI we frequently have these types of challenges frequently with incentives to participate. In addition, one of our senior leaders conducts a weekly mindfulness mediation session. It’s a great way to break up the day and feel energized for the rest of the week. Always, always encourage staff to share ideas, issues and solutions. Your employees have the bird’s eye view of their jobs and many have great insight and suggestions on ways to improve processes or tools. At UASI we do this regularly in our team meetings, but we also have a corporate Innovation Program where anyone can submit ideas for improvement. These ideas are evaluated by a small committee on a regular basis and then the person submitting gets feedback on the idea. If we decide to pursue the idea, many times the submitter participates in crafting the solution. If we decide to not take action at the moment, the submitter is given the rationale. In this way, everyone knows their ideas are valued whether or not we decide to implement them. Your people are what make your company great. Working remotely can be lonely and people can feel isolated so it is important to ensure you have a good engagement program in place. Keep it up or get one or more of these started. Today. Don’t delay.
Respiratory failure: a syndrome in which the respiratory system fails in one or both of the functions of gas exchange, which are oxygenation and carbon dioxide elimination. It can be classified as hypoxemic (type 1), hypercapnic (type 2), or a combination of both. Respiratory failure can be acute or chronic. The etiology of acute respiratory failure is often determined to be pneumonia, bronchiolitis, croup, trauma, or exacerbation of a chronic condition such as asthma. Chronic respiratory failure: a condition in which the inability to effectively exchange carbon dioxide and oxygen results in chronically low oxygen levels or chronically high carbon dioxide levels. Usually the underlying etiology is chronic lung disease such as cystic fibrosis, neuromuscular disorders, or muscular dystrophy. Diagnosis requires the use of home oxygen or ventilator support, or having baseline SaO2 < 88% on room air or pCO2 > 50 with normal pH. Acute respiratory distress syndrome (ARDS): often considered the end stage of acute respiratory failure, occurring when fluid builds up in the alveoli which prevents the lungs from filling with enough air. This leads to less oxygen reaching the bloodstream and organs, reducing organ function. ARDS patients have a moderate to severe impairment of oxygenation as defined by the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PaO2/FiO2). Chest imaging exhibits bilateral opacities/pulmonary edema not explained by cardiac failure or fluid overload. Diagnostic Criteria for Acute Respiratory Failure in Pediatric Patients Pediatric patients often present differently than adults and can also decompensate more quickly. Children may present with the following: Lethargy or irritability Appear anxious or demonstrate inability to concentrate May prefer positioning to aid in breathing (i.e sitting up, leaning chest/head forward) Mouth breathing, drooling Interrupted feeding and diet patterns Generally, oxygen saturation <88% on room air is supportive of acute hypoxemic respiratory failure. ABGs are rarely measured when assessing children’s respiratory function. However, diagnostic ABG levels include: PaO2 of < 60 mmHg on room air Acute increase in pCO2 of 10-15 mmHg pH decreasing to 7.32 or less PaO2 / FiO2 (PF) ratio of < 200 or < 300 Intubation/mechanical ventilation is not required to support the presence of acute respiratory failure. An acute respiratory condition and any of the following treatments may support the presence of acute respiratory failure: Supplemental oxygen with FiO2 ≥ 0.30–0.35 to maintain SpO2 ≥ 90% Any level of high-flow nasal cannula Any level of nasal continuous positive airway pressure (nCPAP) or nasal bilevel positive airway pressure (BiPAP) (except for obstructive sleep apnea) Provider documentation often describes the patient’s symptoms and assessment without stating the words “acute respiratory failure.” If clinical indicators support the presence of acute respiratory failure, a query should be sent. For example, “acute respiratory distress”, “acute exacerbation”, “respiratory insufficiency”, “respiratory acidosis” are frequently used terms that may not capture the patient’s true complexity. Providers frequently use templated notes that are copied/pasted into subsequent notes. This is a great opportunity for CDI to provide education on customizing these templates. Templated notes often have statements such as “no acute distress”, and “normal appearance” which can suggest that the patient did not have respiratory failure. Additional Tips: • Chapter-specific coding guidelines (particularly with newborns) that provide sequencing direction take precedence when determining the principal diagnosis. • A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital. • Although acute respiratory failure always has an underlying cause, do not default to the etiology as the principal diagnosis. The circumstances of the admission must be considered. Respiratory failure may be listed as either the principal or a secondary diagnosis. • For acute respiratory failure due to COVID-19, assign code U07.1, COVID-19, followed by code J96.0-, Acute respiratory failure. • If the documentation is not clear as to whether acute respiratory failure and other conditions are equally responsible for occasioning the admission, query the provider for clarification. • Common respiratory failure risk factors to look out for in pediatric patients include: young age, premature birth, immunodeficiency, chronic pulmonary/cardiac/neuromuscular diseases, anatomic abnormalities, cough/rhinorrhea/other URI symptoms, and lack of immunizations. • Other conditions that are not pulmonary in nature which may lead to acute respiratory failure include: status epilepticus leading to encephalopathy and decreased respiratory drive, a traumatic head injury or anoxic brain injury that stops respiratory drive, and septic shock. References: Pediatric Acute Lung Injury Consensus Conference Group. (2015). Pediatric acute respiratory distress syndrome: Consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Critical Care Medicine, 16(5), 428–439. https://doi.org/10.1097/PCC.0000000000000350 Springer, S. C. (2012, December 5). Pediatric respiratory failure. Medscape. https://emedicine.medscape.com/article/908172-overview Savage, L. (2017). Pediatric CDI Building Blocks for Success (pp. 64–71). HCPro.
