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Monthly CDI Scenario Discussion – December 2020

Topic: Cerebral Palsy

Scenario: 12-year-old male presents with fever, loud breathing and cough

PMH: Premature birth at 28 weeks gestation weighed 680g due to PRM; NICU for 4 mouths; on mechanical vent 7 days then on/off NCPAP then Vapotherm for respiratory distress. Received Surfactant, steroids, vaccines and antibiotics at appropriate times.  NICU diagnoses included: Grade II Right IVH resolved; Hyperbilirubinemia of Prematurity, ROP, Hyponatremia, Bronchopulmonary Dysplasia, GERD, Anemia; Home on O2; apnea monitor and multiple medications. Patient wears glasses due to visual deficits from the ROP.   Patient is able to tolerate a soft/ground diet and drinks from a sippy cup.  Patient requires assistance to feed, wears pull ups, and is wheelchair bound.  Mom states he will sometimes cough when he eats. Patient attends school, has his own aide to assist him in the classroom. Per mom, he generally likes school and his classmates and he is well liked by other students He reads well, but struggles with math. He gets Bs and Cs.  Patient was IQ tested through the school to assure proper classroom placement and has a reported IQ of 61.   Patient has previously been hospitalized with pneumonia and UTI.  At home, mom was giving Tylenol, nebulizer treatments and vest therapy for 2 days without improvement. 

Home Meds: Baclofen, prn Albuterol nebulizer, and vest therapy prn

Clinical Findings: Temp 102.4, P 112, RR 36, 87% RA, 96% on 4LHFNC; A swallow evaluation was attempted but patient was uncooperative

Labs: WBC 18.2, CRP 2.56, Sputum culture: no growth, Covid negative

Chest X-ray: CXR: Findings consistent with pneumonia

PE: Wet, productive cough. Patient having difficulty handling oral secretions.  Thin extremities with spasticity and hypertonia noted to arms and legs. 

Medications: IV Clindamycin, Glycopyrrolate, Pepcid, Albuterol nebulizer q 4hrs, vest therapy QID

Discharge Summary: Pneumonia, CP, possible GERD

Question: Are there query opportunities based on the scenario stated above?


  • Pt. presented with infection, was noted to be febrile with tachycardia, tachypnea and hypoxia on RA, treated with HFNC.
  • Antibiotic selection combined with history and presentation indicate a more specific pneumonia.
  • Cerebral Palsy is documented without further specificity of type or spasticity. Patient is also noted to have a low IQ.

UASI Recommends:

  • Query for Sepsis
  • Query for Aspiration Pneumonia
  • Query for Acute Hypoxic Respiratory Failure
  • Query for Cerebral Palsy type
  • Query for Intellectual Disability

Documentation Without Clarification:

  • Working Principal Diagnosis: Pneumonia, unspecified organism (J18.9)
  • Working Secondary Diagnoses: Cerebral palsy, unspecified (G80.9), Gastro-esophageal reflux disease without esophagitis (K21.9)
  • Working MS DRG: 195 Simple pneumonia & pleurisy w/o CC/MCC
  • RW: 0.6821     GMLOS: 2.6    
  • Working APR DRG: 139 Other pneumonia
  • APRRW: 0.4269          GMLOS: 2.28   SOI/ROM: 1/1

Documentation With Clarification:

  • Working Principal Diagnosis: Sepsis, unspecified (A41.9)
  • Working Secondary Diagnoses: Pneumonitis due to inhalation of food and vomit (J69.0), Acute respiratory failure with hypoxia (J96.01), Spastic quadriplegic cerebral palsy (JG80.0), Mild Intellectual Disability (F70), Gastro-esophageal reflux disease without esophagitis (K21.9)
  • Working MS DRG: 871 Septicemia or severe sepsis without MV >96 hours with MCC
  • RW: 1.86822   GMLOS: 4.8    
  • Working APR DRG: 720 Septicemia and disseminated infections
  • APR RW: 2.0958          GLOS: 6.29      SOI/ROM: 4/4

CDI Educational Tips:

  • When reviewing documentation for cerebral palsy, make sure the following is included:
    • Documentation of the presence of spasticity
    • Documentation of the type of CP
    • Intellectual disability (if present) and severity
  • The assorted cerebral palsy codes are assigned various CC/MCC status:
    • Unspecified and Ataxic Cerebral Palsy (G80.9, G80.4) are non-CCs
    • Spastic Cerebral Palsy (G80.1, G80.2) & Athetoid, Dyskinetic, Dystonic (G80.3) are CCs
    • Spastic Quadriplegic Cerebral Palsy (G80.0) is an MCC
  • Intellectual disability is commonly seen in children with cerebral palsy. When reviewing documentation ensure the following is documented:
    • Any Adaptive behavior problem
      • i.e. language, literacy, self-direction, social skills, or practical skills like activities of daily living, occupation, and safety
    • Any associated comorbid conditions
      • i.e. pressure ulcers, aspiration pneumonia, etc.
    • Document the severity of the Intellectual Disability
      • Borderline intellectual function (IQ 70-84) is considered a learning disability
      • Mild-IQ 50-69
      • Moderate IQ 35-49
      • Severe IQ 20-34
      • Profound-IQ <20
  • Refer to the UASI November Pediatric Sepsis tip of the month for educational information for pediatric sepsis.

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.