Immunodeficiency

By Julie Shayne RN, CCDS, Intermountain Health Peaks Region Clinical Documentation Integrity Educator

Documenting “Immunocompromised State/Immunodeficiency” supports the intensity of your service, severity of illness, risk of mortality, length of stay and risk adjustment metrics.

Document the following conditions if clinically supported:

• Immunocompromised state due to specific medical condition(s), such as certain cancers, genetic disorders, end stage renal disease and poor glycemic control diabetes mellitus

  • End stage renal disease: uremia-associated immunosuppression contributes to high prevalence of infections

• Immunodeficiency due to drugs > medications that interfere with the immune system; includes but is not limited to immunosuppressants, corticosteroids, monoclonal antibodies and chemotherapy

  • COPD

  • Rheumatoid arthritis

  • Chemotherapy

  • Organ transplant rejection

• Immunodeficiency due to external causes, such as exposure to ionizing radiation, bone marrow transplant and splenectomy

  • Lymphoma treated with bone marrow ablation before bone marrow transplant causing secondary immunodeficiency

  • Asplenia due to splenectomy after spleen injury

Case example: Five-day LOS, surgical case with debridement

Remember, your CDI team is here to help you and serve as a resource for your documentation needs to ensure an accurate clinical picture of the patient is reflected. Please email me with any questions.