Attachment 17 TRM 6001-03 Sentry Medical.pdf

Technical Reference Manual

SENTRY

MEDICAL

SMD/ MDS/ DGN

U.S. Department of Justice Federal Bureau of Prisons

OPI: HSD

NUMBER: 6001.03

DATE: 6/8/99

SUBJECT: SENTRY Sensitive

Medical Data/Medical Duty Status/Acuity Status

SENTRY SMD/MDS Technical Reference Manual TRM 6001.03 TABLE OF CONTENTS Page I

Page

OVERVIEW

SECTION 1 SENSITIVE MEDICAL DATA CATEGORY

OUTPATIENT AND INPATIENT MORBIDITY AND PROCEDURES

CLASSIFICATION FORMS - CONSULTANT PROCEDURE CODES

REFERENCE SHEET . . . . . . . . . . . . . . . . . . . . . . . . . 1-1

OUTPATIENT MORBIDITY AND PROCEDURES CLASSIFICATION FORM . . . . . . 1-1

COMPLETION OF OUTPATIENT MORBIDITY AND PROCEDURES FORM . . . . . . . 1-9

PROCEDURES FOR COMPLETING PROCEDURES AND

CLASSIFICATION CODING . . . . . . . . . . . . . . . . . . . . . . 1-13

PROCEDURES FOR PHYSICIAN COMPLETION OF THE CHRONIC

CARE CLINIC BOX . . . . . . . . . . . . . . . . . . . . . . . . . 1-13

PROCEDURE FOR INPATIENT MORBIDITY AND PROCEDURES

CLASSIFICATION FORM . . . . . . . . . . . . . . . . . . . . . . . 1-14

PROCEDURES FOR HIV TESTING, RISK, AND CLASSIFICATION

CODING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-15

PROCEDURES FOR DATA ENTRY . . . . . . . . . . . . . . . . . . . . . 1-17

PROCEDURES FOR DATA ACCESS . . . . . . . . . . . . . . . . . . . . . 1-19

FORMS

OUTPATIENT MORBIDITY AND PROCEDURE CLASSIFICATION FORM . . . . . . 1-21

CONSULTANT PROCEDURE CODES REFERENCE SHEET . . . . . . . . . . . . 1-22

INPATIENT MORBIDITY, OPERATIONS & PROCEDURES

CLASSIFICATION FOR COMMUNITY HOSPITAL . . . . . . . . . . . . . 1-24

SECTION 2 MEDICAL DUTY STATUS CATEGORY

DISABILITY DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . 2-1

PROCEDURES FOR DATA ACCESS . . . . . . . . . . . . . . . . . . . . 2-2

EXAMPLES OF APPROPRIATE MDS DISABILITY ASSIGNMENTS . . . . . . . . . 2-2

SECTION 3 ACUITY STATUS CATEGORY

ACUITY DEFINITIONS (DGN) . . . . . . . . . . . . . . . . . . . . . . 3-1

PROCEDURES FOR CLASSIFYING MEDICAL/SURGICAL INPATIENTS

AND OUTPATIENTS . . . . . . . . . . . . . . . . . . . . . . . . . 3-1

PROCEDURES FOR DATA ACCESS . . . . . . . . . . . . . . . . . . . . . 3-1

PROCEDURES FOR CLASSIFYING THE MENTAL HEALTH POPULATION . . . . . . . 3-1

PROCEDURES FOR DATA ACCESS . . . . . . . . . . . . . . . . . . . . . 3-2

NON MEDICAL REFERRAL CENTER INSTITUTIONS . . . . . . . . . . . . . . 3-2

SECTION 4 TRANSACTION DESCRIPTIONS

PP30 - CENSUS/ROSTER . . . . . . . . . . . . . . . . . . . . . . . 4-1

SMD EXAMPLES . . . . . . . . . . . . . . . . . . . . . . . . . 4-1

MDS EXAMPLES . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-3

DGN EXAMPLES . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-8

ERROR CORRECTION PROCEDURES . . . . . . . . . . . . . . . . . . . 4-12

ENTRY SMD/MDS Technical Reference Manual TRM 6001.03 TABLE OF CONTENTS Page II

SECTION 5 CODES

SMD GROUP CODES . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1

MDS GROUP CODES . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-2

DIAGNOSIS (DGN) CATEGORY . . . . . . . . . . . . . . . . . . . . . . 5-3

MDS REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-4

SECTION 6 ASSIGNMENT CODES

SMD CATEGORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1

OVERVIEW Page 1

OVERVIEW

The purpose of this manual is to provide technical/step-by-step instructions to Health Services staff for form completion, data entry/retrieval, and monitoring methods for the Sensitive Medical Data (SMD), Medical Duty Status (MDS), and DGN categories.

SENSITIVE MEDICAL DATA CATEGORY Page 1-1

SENSITIVE MEDICAL DATA (SMD)

OUTPATIENT AND INPATIENT MORBIDITY AND PROCEDURES CLASSIFICATION

FORMS - CONSULTANT PROCEDURE CODES REFERENCE SHEET

A copy of the Outpatient Morbidity and Procedures Classification form is available through the Automatic Forms Ordering Process. (Alternative data entry forms may be used for SMD data entry; however, only those codes listed on the Outpatient Morbidity and Procedures Classification form may be used.)

Additional copies of this form can be ordered from Documents Control, Central Office, Washington, D.C., or may be reproduced locally. (This form will be printed in black ink on white paper.)

A copy of the Inpatient Morbidity and Procedures Classification form is included in this manual and copies of this form can be reproduced locally.

A copy of the Consultant Procedure Codes Reference Sheet is included in this manual and copies of this form can be reproduced locally.

OUTPATIENT MORBIDITY AND PROCEDURES CLASSIFICATION FORM: An Outpatient Morbidity and Procedures Classification form must be completed by the listed providers (ET, RN, NP, PA, DR, CI, CE, TM), for all outpatient encounters both on-site and off-site except:

- dental clinic visits

- visits for drug refills only

- intake screening exams, unless a complete history/physical examination is provided

- visits solely for over-the-counter medications

- daily maintenance visits such as BP checks, blood sugars, insulin injections

- psychology encounters (including contract/consultant psychology staff).

- inmates in Diagnostic and Observation (D&O) or Forensic status

- routine visual screening

The exception for D&O and/or Forensic inmates would be institutions desiring to track Chronic Care Clinic assignments for these inmates. Chronic Care Clinic assignments may be entered for D&O and/or Forensic inmates.

Providers RN and ET will be used to capture data for patient encounters for the following only:

- Assessment (BP1) - This code should be used for those encounters completed by EMT’s or RN’s in which the patient is seen for assessment (including triage) and the entry is documented in the medical record.

ENTRY SMD/MDS Technical Reference Manual TRM 6001.03 SENSITIVE MEDICAL DATA CATEGORY Page 1-2

- Emergency/Treatment (BP2) - This code should be used for all emergency situations in which the EMT or RN assesses and provides treatment (based on protocols) and documents in the medical record. This code (BP2) should also be used for outpatient dialysis or chemotherapy treatments.

- Education/Counseling (BP3) - Should be used for encounters in which the primary purpose is patient education and/or counseling. These encounters must be documented in the inmate’s medical record.

Note: LPNs who perform PPD readings will complete the form to document the PPD test results and will use RN as the provider type. LPNs are not authorized for any other SMD entries.

The Provider Code TM will be used to capture all telemedicine encounters.

TB Infection. The following are instructions regarding the codes listed on the Outpatient Morbidity and Procedures Classification form.

1. PPD Result. All inmates tested will have their results entered into this category. The date the test was read will be entered (mm-dd-yyyy). The reading will also be entered using the largest diameter reading in millimeters of induration. The SMD database accepts readings up to and including 40 millimeters.

All readings over 40 millimeters should be coded and entered as 40.

All readings require a provider type be entered when keying the data into SENTRY SMD. If an LPN performs the reading of the PPD the provider type used will be RN, since LPNs work under the supervision of an RN.

a. Inmates who report or have recorded a ?history of positive PPD? without an actual PPD measurement in millimeters should have their PPD repeated as per TRM 6100.01. PPDs can be safely readministered without serious sequelae. Exceptions to retesting such persons with ?a history of a positive PPD? include the following:

(1) Persons with a history of active TB or recently diagnosed active TB: Code using the appropriate active TB code, leaving the PPD result blank. Schedule follow-up chest x-rays as medically indicated.

(2) Persons who have completed isoniazid prophylaxis as documented in the medical record or by inmate self-report if deemed reliable by the evaluating provider: Code using the appropriate prophylaxis code, leaving the PPD result blank. If the history of prophylaxis is questionable, repeat the PPD, record the measurement and prescribe prophylaxis if indicated.

SENSITIVE MEDICAL DATA CATEGORY Page 1-3

(3) Persons with a history of a severe PPD reaction such as whole arm blistering: document history of severe reaction in the medical record, code for annual chest x-ray, leave the PPD result blank.

b. Inmates who refuse tuberculin skin testing should be repeatedly counseled about the importance of testing and encouraged to accept testing in accordance with BOP policy. If no PPD result is obtained (chest x-ray obtained only), the PPD result should be left blank, and the inmate scheduled for a PPD the following year.

2. TB Prophy. All inmates testing PPD positive must have one of the six available SMD codes (795.5A - 795.5F)listed. Only one code should be listed as current at any given time. As inmates complete prophylaxis treatment the codes must be replaced to reflect their current status at all times.

The following are definitions for the six codes.

ON TB PROPHY (795.5A) should be coded for all inmates with a positive tuberculin skin test who are currently prescribed isoniazid or other chemoprophylaxis for tuberculosis in accordance with TRM 6100.01. The effective date associated with this code should be the date prophylaxis was initiated. This code should also be used for the rare cases of inmates with a negative tuberculin skin test for whom tuberculosis chemoprophylaxis is medically indicated, e.g. HIV seropositive inmate who is a close contact of an active tuberculosis case.

TB PROPHY COMPLETE (795.5B) should be coded for all inmates who have completed directly observed chemoprophylaxis for tuberculosis during BOP incarceration. The effective date associated with this code should be the date prophylaxis was completed.

+PPD NO TB PROPHY INDICATED (795.5C) should be coded for all inmates with a positive tuberculin skin test of 10 millimeters or greater for whom tuberculosis chemoprophylaxis is not medically indicated in accordance with TRM 6100.01.

TB PROPHY REFUSED (795.5D) should be coded for all inmates for whom tuberculosis chemoprophylaxis is medically indicated in accordance with TRM 6100.01, but has never been initiated because of the inmate’s refusal. Note: this code should also be used for inmates who had been prescribed isoniazid prior to incarceration and did not complete treatment AND now refuse treatment during BOP incarceration.

TB PROPHY INCOMPLETE (795.5E) should be coded for all inmates for whom tuberculosis chemoprophylaxis was medically indicated and initiated during incarceration but not completed because of drug toxicity, inmate release, noncompliance or other reason.

SENSITIVE MEDICAL DATA CATEGORY Page 1-4

TB PROPHY HX (795.5F) should be coded for all inmates for whom tuberculosis chemoprophylaxis was completed prior to BOP incarceration.

3. TB Testing. For inmates testing PPD negative, code V74.1, along with their next due date (annual testing), must be entered.

The annual due date will be one year from the date the PPD test was read. (Example: If an inmate is given a PPD test on 01-19- 1998 and has it read on 01-21-1998 the annual due date entered in this category will be 01-21-99). All institutions must use the date one year from the date the negative PPD was read for annual testing date.

Code V00.0 will be used for annual chest x-ray testing of those inmates requiring annual testing. The annual due date will be one year from the date the chest x-ray was taken.

The following are definitions.

NEGATIVE TEST. PPD of 0-4 millimeters for inmates with a history of recent contact with a confirmed case of active tuberculosis or diagnosis of HIV infection or other immunocompromised condition.

PPD 0-9 millimeters for all other inmates.

POSITIVE TEST. PPD of 5 millimeters and over for inmates with a history of recent contact with a confirmed case of active tuberculosis or diagnosis of HIV infection or other immunocompromised condition. PPD of 10 millimeters and over for all other inmates.

NOTE: Inmates testing PPD positive or who are otherwise candidates for prophylaxis should be referred to a physician for assessment in accordance with TRM 6100.01, and determination of the prophylaxis category for SMD.

4. TB Disease. The following are the definitions and appropriate codes for active tuberculosis and suspected tuberculosis.

Note: Active TB is routinely diagnosed by a positive culture.

Inmates with clinical evidence of TB with negative cultures and a favorable response to treatment should also be classified as an active TB case.

The following are definitions.

TUBERCULOSIS (PULM TRMT) (011.90) should be coded for all inmates who are diagnosed with active pulmonary or miliary (disseminated) tuberculosis disease that is not multi-drug resistant and are currently on drug treatment whether or not they are considered contagious or noncontagious. Active pulmonary tuberculosis is diagnosed by culture or empirically diagnosed based on clinical presentation and a favorable response to tuberculosis treatment.

SENSITIVE MEDICAL DATA CATEGORY Page 1-5

TUBERCULOSIS (EXTRAPULM TRMT) (017.90) should be coded for all inmates who have been diagnosed and are currently being treated for active extrapulmonary tuberculosis that is not multi-drug resistant.

TUBERCULOSIS (MDR-TB TRMT) (V09.71) should be coded for all inmates who have been diagnosed with pulmonary or extrapulmonary multi-drug resistant tuberculosis disease and are currently being treated whether they are considered contagious or non-contagious.

Multi-drug resistant tuberculosis is pulmonary or extrapulmonary tuberculosis that is resistant to two or more anti-tuberculosis medications.

TUBERCULOSIS (TRMT COMPLETE) (V12.01) should be coded for all inmates who have been diagnosed with pulmonary, extrapulmonary, or multi-drug resistant tuberculosis disease and have completed a course of drug treatment during BOP incarceration.

TUBERCULOSIS (HISTORY OF TRMT) (V12.01H) should be coded for all inmates who have been diagnosed with active pulmonary, extrapulmonary, or multi-drug resistant tuberculosis and completed treatment prior to BOP incarceration.

TUBERCULOSIS SUSPECT (V71.2) should be coded for any inmate that is being clinically evaluated for active tuberculosis while awaiting diagnostic confirmation. Inmates with negative TB cultures, but with clinically suspected TB that improves with treatment, should be treated as culture-negative TB and recorded as an active pulmonary TB case after two months of drug therapy.

NOTE: The tuberculosis codes, including TB suspect, must be routinely monitored and updated as the status changes. Inmates listed as active and then complete treatment should be updated.

Inmates entered as TB suspect should be updated as soon as active TB is ruled out or confirmed.

HIV CLASSIFICATION: All inmates diagnosed with HIV infection must be classified with one and only one HIV classification based on the 1993 Centers for Disease Control Classification System (see TRM 6100.01). For classification purposes, Category B conditions take precedence over Category A; and Category C conditions take precedence over Category B conditions. The lowest accurate CD4+ T-lymphocyte count or percentage (not necessarily the most recent) should be used to determine the appropriate HIV classification. All inmates classified as Category C1, C2, or C3 must have an associated AIDS condition identified. With the exception of active tuberculosis codes, (011.90, 017.90, V09.71, and V12.01H) all AIDS-related conditions are listed separately on the SMD form. The HIV classifications should be downgraded as inmates progress from A to B to C categories, or from 1 to 2 to 3 categories but NEVER in reverse, i.e. with clinical improvement.

SENSITIVE MEDICAL DATA CATEGORY Page 1-6

The D1 code should be used for all inmates who refuse immunologic staging (CD4+ T-cell assessment) or otherwise cannot be staged, and therefore, cannot be assigned a CDC classification. The D1 should NOT be used for inmates who are otherwise in the process of being classified.

The provider completing the Outpatient Morbidity and Procedures Classification form listing HIV classification codes must indicate the ?Add? column for inmates in which there is no existing classification entered into SENTRY. The provider should indicate ?Rep? for replacing one assignment (A1) with another (A2) and should indicate the CURR CLASS (current classification) column for the classification that is being replaced.

NOTE: Record HIV classification only during encounters when the inmate has been newly classified or reclassified.

Other HIV Patient Visit (000.0) should be used only for patient encounters for HIV/AIDS patients in which no other diagnosis/procedure code is applicable. Example: An HIV or AIDS patient is seen for a chronic care clinic visit in which there is no other appropriate diagnostic or procedural code (patient presents to the clinic appointment with no complaints or illnesses) for the encounter.

AIDS Conditions: All listed codes are used only for inmates with an HIV Classification of C1, C2, or C3. These codes have the suffix of Z which identifies the condition as associated with AIDS, since many of the conditions may also be present in patients without AIDS.

The following are definitions:

CANDIDIASIS - ESOPHAGEAL (112.84Z) should be coded for all HIV seropositive inmates diagnosed with esophageal candidiasis according to the following criteria:

1. Gross inspection by endoscopy or by microscopy of a specimen from the esophageal mucosa; or

2. Onset of retrosternal pain on swallowing AND oral candidiasis diagnosed by the gross appearance of white patches or plaques on an erythematous base or by the microscopic appearance of fungal mycelial in an uncultured specimen scraped from the oral mucosa.

CERVICAL CANCER - INVASIVE (180.9Z) should be coded for all HIV seropositive inmates with cervical cancer diagnosed by biopsy and microscopy of the affected tissue and staged as invasive.

COCCIDIOIDOMYCOSIS-EXTRAPULMONARY (114.9Z) should be coded for all HIV seropositive inmates with coccidioidomycosis at a site, other than or in addition to the lungs, diagnosed by microscopy culture, or detection of antigen in a specimen obtained directly from the affected tissue or associated fluids.

SENSITIVE MEDICAL DATA CATEGORY Page 1-7

CRYPTOCOCCOSES-EXTRAPULMONARY (117.5Z) should be coded for all HIV seropositive inmates with extrapulmonary cryptococcoses diagnosed by microscopy, culture, or detection of antigen in a specimen obtained directly from the tissues affected or associated fluids.

CRYPTOSPORIDIOSIS-CHRONIC (007.4Z) should be coded for all HIV seropositive inmates with cryptosporidiosis diagnosed by microscopy and causing diarrhea for greater than one month.

CYTOMEGALOVIRUS-RETINITIS OR INFECTION OF ORGANS OTHER THAN LYMPH

NODES OR LIVER (078.5Z) should be coded for all HIV seropositive inmates diagnosed with cytomegalovirus infection in accordance with the following criteria:

1. CMV retinitis diagnosed by characteristic fundoscopic evidence of infection with visual impairment (e.g. discrete patches of retinal whitening with distinct borders, spreading in a centrifugal manner along the paths of blood vessels, progressing over several months, and frequently associated with retinal vasculitis, hemorrhage, and necrosis); or

2. CMV pneumonitis, esophagitis, colitis, encephalitis or other body organ infection, excluding liver and lymph nodes, diagnosed by pathology or histology of the affected tissue (positive serum antibody or positive blood cultures are not sufficient to confirm end-organ CMV infection).

ENCEPHALOPATHY/DEMENTIA - HIV (348.3Z) should be coded for all HIV seropositive inmates with clinical findings of disabling cognitive or motor dysfunction interfering with the activities of daily living progressing over weeks to months in the absence of a concurrent illness or condition other than HIV infection that could explain the findings.

HERPES SIMPLEX - > 1 MONTH (054.9Z) should be coded for all HIV seropositive inmates with end-organ infection with herpes simplex (e.g. esophagitis), or mucocutaneous ulcers clinically persisting for greater than one month that are proven by microscopy, culture, or detection of herpes antigen in a specimen obtained directly from the affected tissue.

HISTOPLASMOSIS - EXTRAPULMONARY (115.9Z) should be coded for all HIV seropositive inmates with histoplasmosis, diagnosed at a site other than or in addition to the lungs, cervical or hilar lymph nodes, and proven by microscopy, culture, or detection of antigen in a specimen obtained directly from the affected tissues or associated fluids.

ISOSPORIASIS (007.2Z) should be coded for all HIV seropositive inmates with chronic diarrhea greater than one month and diagnosed with isosporiasis infection proven by microscopy.

SENSITIVE MEDICAL DATA CATEGORY Page 1-8

KAPOSI’S SARCOMA (176.9Z) should be coded for all HIV seropositive inmates diagnosed with Kaposi’s sarcoma diagnosed by biopsy or clinically by a dermatologist or other expert physician.

LYMPHOMA - BURKITT’S/IMMUNOBLASTIC/BRAIN PRIMARY (200.20Z) should be coded for all HIV seropositive inmates with Burkitt’s, immunoblastic, or primary brain lymphoma proven by biopsy.

MYCOBACTERIUM TUBERCULOSIS (011.90, 017.90, V09.71, V12.01, and V12.01H) (Tuberculosis Disease) should be coded with the applicable code for all HIV seropositive inmates with tuberculosis disease.

MYCOBACTERIUM AVIUM COMPLEX -MAC (031.0Z) should be coded for all HIV seropositive inmates with Mycobacterium Avium cultured from blood or other normally sterile end-organ site (does not include positive sputum or stool cultures without evidence of progressive pulmonary disease or enterocolitis respectively).

MYCOBACTERIUM OTHER - NON TB (031.9Z) should be coded for all HIV seropositive inmates with Mycobacterium species infections other than TB or MAC cultured from blood or other normally sterile end-organ site(s) (does not include positive sputum or stool cultures without evidence of progressive pulmonary disease or enterocolitis respectively).

PML (046.3Z) should be coded for all HIV seropositive inmates with progressive multifocal leukoencephalopathy diagnosed by microscopy or other radiographic AND clinical findings consistent with PML as determined by an expert subspecialist.

PCP (136.3Z) should be coded for all HIV seropositive inmates diagnosed with Pneumocystis carinii pneumonia in accordance with the following criteria:

1. Histologically proven PCP; or

2. A history of dyspnea on exertion or non-productive cough within the past 3 months AND chest x-ray evidence of diffuse bilateral interstitial infiltrates AND arterial blood gas analysis showing an arterial p02 of < 70 mm Hg or a low respiratory diffusing capacity (<80% of predicted values) or an increase in the alveolar-arterial oxygen tension gradient, AND no evidence of bacterial pneumonia.

PNEUMONIA RECURRENT (486Z) should be coded for all HIV seropositive inmates with more than one episode of pneumonia in a one-year period diagnosed by the following:

SENSITIVE MEDICAL DATA CATEGORY Page 1-9

1. Culture (or other organism-specific diagnostic method) obtained from a clinically reliable specimen or a pathogen that typically causes pneumonia (other than PCP or TB) for at least one of the cases of pneumonia;

and

2. Radiographic evidence of pneumonia for all cases.

SALMONELLA-RECURRENT SEPSIS (003.1Z) should be coded for all HIV seropositive inmates with blood cultures recurrently positive for nontyphoidal salmonella.

TOXOPLASMOSIS - CNS (130.9Z) should be coded for all HIV seropositive inmates with toxoplasmosis diagnosed in accordance with the following criteria:

1. Histologically confirmed toxoplasmosis by brain biopsy;

or

2. Clinically diagnosed central nervous system toxoplasmosis as evidenced by the onset of focal neurological findings consistent with intracranial disease AND radioimaging findings consistent with toxoplasmosis, AND serum antibody to toxoplasmosis or successful response to therapy for toxoplasmosis.

WASTING SYNDROME (799.4Z) should be coded for all HIV seropositive inmates with findings of profound involuntary weight loss >10% of baseline body weight AND chronic diarrhea (two or more loose stools per day for >30 days) or chronic weakness and documented fever (>30 days) in the absence of concurrent illness or condition other than HIV infection that could explain the findings.

Hepatitis Codes

Hepatitis A (acute IgM+) 070.1

Should be coded for all inmates newly diagnosed with acute hepatitis A viral infection during BOP incarceration, confirmed by a positive IgM serology. The acute hepatitis A code should remain in SENTRY even after the hepatitis has resolved. Inmates with a past history of acute hepatitis A before BOP incarceration should not be entered into SENTRY.

Hepatitis B (acute, HBc IgM+) 070.30

Should be coded for all inmates newly diagnosed with acute hepatitis B viral infection during BOP incarceration, confirmed by a positive IgM antibody to hepatitis B core antigen (anti- HBc). The acute hepatitis B code should remain in SENTRY even after the acute hepatitis has resolved. Inmates with a past history of acute hepatitis B before BOP incarceration should not be entered into SENTRY.

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Hepatitis B (chronic, HbsAg+) 070.32

Should be coded for all inmates who currently have chronic hepatitis B infection confirmed by a positive hepatitis B surface antigen (HBSAG) regardless of when initial infection with hepatitis B virus occurred. Inmates who have chronic hepatitis B infection may clear their infection spontaneously or with drug therapy, usually confirmed by the loss of HBSAG and the development of antibodies to HBSAG. The code for chronic hepatitis B infection should be deleted from SENTRY for all inmates who clear their infection, as indicated by the loss of

HBSAG.

Hepatitis C (acute) 070.51

Should be coded for all inmates who have been newly diagnosed with acute hepatitis C viral infection during BOP incarceration.

There is no specific serologic marker for acute hepatitis C. The diagnosis of acute hepatitis C should be based on a positive antibody to hepatitis C virus (anti-HCV) and clinical or laboratory evidence of acute hepatitis, without evidence of other viral or noninfectious causes of acute hepatitis. The code for acute hepatitis C should remain in SENTRY even after acute hepatitis C has clinically resolved. Inmates with a past history of acute hepatitis C before BOP incarceration should not be entered into SENTRY.

Hepatitis C (chronic) 070.54

Should be coded for all inmates who have currently been diagnosed with chronic hepatitis C viral infection, regardless of when initial infection with hepatitis C virus occurred. For inmates with risk factors for HCV infection and elevations in hepatocellular enzymes, a positive enzyme immunoassay (EIA-2) for HCV antibodies is considered confirmatory for chronic HCV infection for SMD reporting purposes. For inmates without risk factors for HCV infection or normal hepatocellular enzymes a confirmatory recombinant immunoblot assay (RIBA) should be performed. The code for chronic hepatitis C infection should not be deleted even with successful drug therapy, since relapse is possible.

Hepatitis (unknown) 070.9

Should be coded for all inmates who currently have hepatitis of unknown etiology. The code should be deleted if the hepatitis has resolved.

STD Codes

Chlamydia 079.88

Should be coded for all inmates who are newly diagnosed with Chlamydia trachomatis infection as confirmed by the isolation of C. trachomatis by culture or the demonstration of C. trachomatis

SENSITIVE MEDICAL DATA CATEGORY Page 1-11 in a clinical specimen by detection of antigen or nucleic acid.

The code for inmates diagnosed with chlamydia should not be Chlamydia trachomatis infection as confirmed by the isolation of C. trachomatis by culture or the demonstration of C. trachomatis in a clinical specimen by detection of antigen or nucleic acid.

The code for inmates diagnosed with chlamydia should not be deleted from SENTRY even after successful drug therapy has been administered. Inmates with a past history of adequately treated chlamydial infections before BOP incarceration should not be entered into SENTRY.

Gonorrhea (acute) 098.1

Should be coded for all inmates who are newly diagnosed with acute gonorrhea during BOP incarceration. Gonorrhea is confirmed by the isolation of typical gram-negative, oxidase-positive diplococci (presumptive Neisseria gonorrhoeae) from a clinical specimen, or demonstration of N. gonorrhoeae in a clinical specimen by detection of antigen or nucleic acid, or observation of gram-negative intracellular diplococci in a urethral smear obtained from a male. The code for inmates diagnosed with gonorrhea should not be deleted from SENTRY even after successful drug therapy has been administered. Inmates with a past history of adequately treated gonorrhea before BOP incarceration should not be entered into SENTRY.

Syphilis Primary 091.0

Should be coded for all inmates who are newly diagnosed with primary syphilis during BOP incarceration. Primary syphilis is confirmed by the laboratory demonstration of Treponema pallidum in clinical specimens by darkfield microscopy or direct fluorescent antibody testing. For SMD coding purposes, primary syphilis should be reported if confirmed by the laboratory; or if the case is clinically compatible with syphilis with one or more ulcers (chancres) consistent with primary syphilis and a reactive serologic test (nontreponemal: Venereal Disease Research Laboratory (VDRL) or rapid plasma reagin (RPR); or treponemal:

fluorescent treponemal antibody absorbed (FTA-ABS) or microhemagglutination assay for antibody to T. pallidum (MHA-TP).

Nontreponemal or treponemal tests, although usually positive in primary syphilis, can at times be negative since the infection is in its earliest stage. The code for inmates currently diagnosed with primary syphilis should not be deleted from SENTRY even after curative drug therapy has been administered. Inmates with a past history of adequately treated primary syphilis prior to BOP incarceration should not be entered into SENTRY.

Syphilis Secondary 091.9

Should be coded for all inmates who are newly diagnosed with secondary syphilis during BOP incarceration. Secondary syphilis is clinically characterized by localized or diffuse mucocutaneous lesions, often with generalized lymphadenopathy, with or without

SENSITIVE MEDICAL DATA CATEGORY Page 1-12 the presence of the primary chancre. For SMD coding purposes, secondary syphilis should be reported if a clinically compatible case is confirmed by the laboratory demonstration of T. pallidum in a clinical specimen or is suggested by a nontreponemal (VDRL or RPR) titer greater than or equal to 4 with a positive confirmatory treponemal test. The code for inmates currently diagnosed with secondary syphilis should not be deleted from SENTRY even after curative drug treatment has been administered.

Inmates with a past history of adequately treated secondary syphilis prior to BOP incarceration should not be entered into

SENTRY.

Syphilis Early Latent 092.9

Should be coded for all inmates newly diagnosed with early latent syphilis during BOP incarceration. For SMD coding purposes early latent syphilis should be reported if initial T. pallidum infection has occurred within the preceding 12 months without current signs or symptoms of infection but with a reactive nontreponemal and a confirmatory treponemal test. Infection during the preceding 12 months is suggested by any of the following: documented seroconversion or fourfold or greater increase in titer of a nontreponemal test during the previous 12 months, or a history of symptoms consistent with primary or secondary syphilis during the previous 12 months, or a history of sexual exposure to a partner who had confirmed or probable primary or secondary syphilis or probable early latent syphilis (documented independently as duration < 1 year), or reactive nontreponemal and treponemal tests in an inmate whose only possible exposure occurred within the preceding 12 months. The code for inmates currently diagnosed with early latent syphilis should not be deleted from SENTRY even after curative drug treatment has been administered . Inmates with a past history of successfully treated early latent syphilis prior to BOP incarceration should not be entered into SENTRY.

Syphilis Unknown Duration 097.9

Should be coded for all inmates with syphilis of unknown duration or late latent syphilis greater than 1 year in duration. For SMD coding purposes syphilis of unknown duration or late latent syphilis should be reported if T. pallidum infection is documented by a reactive nontreponemal and a confirmatory treponemal test in an inmate without signs or symptoms of primary, secondary, or tertiary syphilis for whom there is no evidence that initial infection occurred in the past 12 months.

The code for inmates currently diagnosed with syphilis of unknown duration or late latent syphilis should not be deleted from SENTRY even after curative drug treatment has been administered.

Inmates with a past history of successfully treated syphilis of unknown duration prior to BOP incarceration should not be entered into SENTRY.

SMD/MDS Technical Reference Manual TRM 6001.03 SENSITIVE MEDICAL DATA CATEGORY Page 1-13

Syphilis Tertiary 097.0

Should be coded for all inmates with clinical manifestations of late syphilis and a reactive treponemal test. Inflammatory syphilitic lesions of late syphilis can occur in the SENTRY cardiovascular system, skin, bone, or internal organs.

Demonstration of T. pallidum organisms in late syphilitic lesions by fluorescent antibody or special stains is confirmatory, but these studies are not always feasible or positive. Involvement of the nervous system (neurosyphilis) can occur during primary, secondary, or tertiary syphilis and should be coded with the associated stage of infection. The code for inmates currently diagnosed with tertiary syphilis should not be deleted from SENTRY even if curative drug treatment has been administered.

Inmates with a past history of successfully treated tertiary syphilis prior to BOP incarceration should not be entered into

SENTRY.

All other infectious diseases should be reported in SMD if confirmed as cases in accordance with the Centers for Disease Control and Prevention Case Definitions for Infectious Conditions Under Public Health Surveillance, MMWR Vol. 46, No. RR-10, May 2, 1997.

COMPLETION OF OUTPATIENT MORBIDITY AND PROCEDURES FORM:

Reg. No.: Write the inmate's register number. Be sure the number is accurate. Imprint plates or name labels can be used.

Name: Write the inmate's name. Write legibly.

Time of Visit: Write the time the inmate visited the Health Services Unit. Use military time, e.g., for 2:00 PM write 1400.

The time must correspond to the time documented in the medical record for the patient encounter.

Date of the Visit: Write the date the inmate visited the Health Services Unit (HSU) in the following format: MM-DD-YYYY.

Provider's Initials: The provider who completes the form should legibly sign his/her initials.

Type of Provider: Circle the code appropriate for the provider of the services. The types of provider are:

Emergency Medical Tech ET Nurse (Registered) RN

Nurse Practitioner NP Physician Assistant PA Physician DR

Consultant Internal CI (physicians only) Consultant External CE

Telemedicine TM

SENSITIVE MEDICAL DATA CATEGORY Page 1-14

The categories of providers ET and RN are limited to using only the three codes listed under ET/NURSE on the Outpatient Morbidity and Procedures Classification form. No other SMD codes should be used for Registered Nurse or EMT encounters.

The provider will circle the appropriate provider code. If more than one provider cares for the patient, each provider must document in the medical record and complete a separate Classification form.

The classification category EMT/NURSE is to be used by Emergency Medical Technicians and Registered Nurses only. Treatment provided by LPNs (other than PPD readings as previously stated), or other ancillary staff will not be recorded in the SMD system.

For off-site outpatient treatment, an Outpatient Morbidity and Procedures Classification form must be completed. An encounter with a consultant outside of the confines of the institution will be coded consultant external (CE). An encounter with a consultant inside the confines of the institution will be coded consultant internal (physician only),(CI). A visit to a community hospital that does not result in an overnight admission will be classified as a consultant external (CE). All telemedicine encounters will be coded telemedicine (TM).

The Health Services Administrator (HSA) will designate a staff member to track and code the Outpatient Morbidity and Procedures Classification form for all Consultant External visits. The HSA will develop procedures appropriate for obtaining the ICD-9-CM codes from the consultant. It is recommended the consultant be required to provide the code in the billing.

Diagnosis/Classification. The diagnoses and procedures are under 18 classification categories:

Cardiovascular Miscellaneous Ears and Eye Musculoskeletal

EMT/Nurse Neoplasms Gastrointestinal Neurological

General Radiology Genitourinary Respiratory

Infectious Skin Injuries Symptoms Mental Disorders HIV

The 18 classification categories include the most common diagnoses/conditions and procedures for which inmate patients are treated. The number to the right of each diagnosis, operation and procedure is the ICD-9-CM code or CDC HIV code. It is this code and not the narrative diagnosis that will be circled and entered into SENTRY. DO NOT circle the entire narrative diagnosis.

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The following rules will be followed when selecting an ICD-9-CM code:

a. The diagnoses/procedures circled should correspond to the entry in the medical record. Only those procedures and/or diagnoses written in the note and treated should be entered.

b. The provider will circle THE CODE NUMBER ONLY of all diagnoses/injuries/procedures treated during the visit. A symptom should be circled ONLY if a related diagnosis is NOT made.

c. If a patient has an existing condition that is NOT treated during the encounter it should NOT be circled.

d. If a patient does not show up for an encounter (appointment, call-out, sick-call), "No Show - V64.3" under the MISCELLANEOUS section should be circled (a SF-600 note still needs to be documented). No other diagnosis/condition should be circled.

e. If a patient has a diagnosis/condition/symptom that does not fit into any of the other 18 classification categories, circle "Other General Diagnosis" (V65.8) in the GENERAL category.

f. For all injuries "Assault = A", "Occupational = O", "Recreational = R" or "Accidental = X", ?Self Inflicted = S? is to be circled to indicate whether the inmate was injured by assault, at work, during a recreational activity, self inflicted, or accidentally. All injuries are coded generically. For instance, a fracture of the femur will be coded to "Fracture."

Consequently, morbidity statistics will not be available according to different sites of fracture, only by total fractures. The same is true of lacerations, burns, dislocations, etc. (When keying in the code number, key in the four-digit code number, then space, then add the suffix A, O, R, X or S.)

g. Diagnoses, whether acute or chronic, will be coded to unspecified, for example, chronic bronchitis will be coded to simply "bronchitis."

The code V67.4 follow-up fracture should be used when the patient returns for subsequent visits. This code may be found in the Musculosketal category.

h. Several separate entries on the Outpatient Morbidity and Procedures Classification form have the same ICD-9-CM code number. For example, in the GASTROINTESTINAL category "colitis" and "diarrhea" and "gastroenteritis" are all coded to 558.9.

They are listed separately for ease in location. The collective data for 558.9 from SENTRY will be reported as

"COLITIS/DIARRHEA/GASTRO."

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I. Inmates who have a diagnosis that will require their continued participation in a clinic (e.g. diabetes, hypertension) will no longer be identified by pre-identified diagnoses. The procedure is to enter the correct clinic assignment from the form along with the date/time of the next exam. Then, enter the diagnostic or procedural code relating to the visit along with the date/time of the encounter. Future dates/times should be keyed for chronic care clinic assignments, but not for any of the diagnosis or procedure assignments. Provider code is not entered when placing an inmate in a clinic. A PP30 roster will be used to identify chronic clinic patients and their next scheduled visit. Note: The asterisk codes remain as current assignments on the inmate profile, however, this does not automatically place the inmate in a clinic. Only the codes in the Chronic Care Clinic(CCC)box are recognized as inmates in CCC.

j. If a patient is being seen for an Intake History/ Physical examination, circle only "Intake History/Physical - V70.3" and NOT any conditions that are found during the examination unless treatment is initiated at the time of the examination. V70.3 should not be used for intake screening unless the complete physical is provided at that time. When the history/physical takes place on different dates, only the completed physical date, (NOT the partial examination) will be entered using the code V70.3

k. If a patient is seen for an annual, biennial, or release history and physical examination, circle only "Interval History/Physical - V70.5" and NOT any conditions that are found unless treatment is initiated at the time of the examination.

l. If a patient is seen with a suspected condition (suspected by patient or medical staff) and nothing is found circle "Suspected condition, nothing found" (V71.8) in the MISCELLANEOUS category.

m. If a patient is being seen as an outpatient for a follow-up of a previously diagnosed condition, circle the code which best describes the reason the patient is currently being seen.

n. Inmates in Special Housing Units (A/D, D/S, etc.)

should only have an entry if medical assistance is requested.

Inmates who have no complaints and/or are just given medications would not constitute a patient encounter for SMD entry.

o. Future dates will be used when tracking chronic care clinics, mammograms, PAP smears, PPD skin tests, and PPD chest x-rays. A PP30 roster will be used to identify patients and their next scheduled testing.

SENSITIVE MEDICAL DATA CATEGORY Page 1-17

Examples:

(1) If the patient had been seen for a Myocardial Infarct (410.9) and is in for a follow-up appointment he should be coded OTHER CARDIOVASCULAR DIAGNOSIS (459.8).

(2) If the patient was seen for Otitis Media (382.9) and is in for a follow-up for the same complaint, it would be coded OTITIS MEDIA (382.9).

(3) Patients coded for accidental fracture 829.0(X) will be coded FOLLOW-UP FRACTURE V67.4 for subsequent visits.

PROCEDURES FOR COMPLETING PROCEDURES CLASSIFICATION CODING:

a. The common procedures performed within BOP institutions are listed under the most appropriate diagnostic category on the Outpatient Morbidity and Procedures Classification form. Most sections have an "other procedures" code that may be used if the specific procedure performed does not appear on the form.

b. For consultant visits a reference list of ICD-9-CM Procedure codes is provided for SMD entry.

c. Only the procedure codes listed on the Outpatient Morbidity and Procedures Classification form and/or Consultant Procedure Code Reference Sheet may be used. The most appropriate code should be selected. The "other procedures" code should only be used if no other code is appropriate.

PROCEDURES FOR PHYSICIAN COMPLETION OF THE CHRONIC CARE CLINIC

BOX:

a. The ADD function is to be used upon initial placement of an inmate into a chronic care clinic. Check the appropriate block and the date and time of the next exam.

b. The DEL function is to be used when the inmate no longer requires participation in a chronic care clinic. Check the appropriate block.

c. The Date of Next Exam is to be completed when the inmate being treated is a current participant in a chronic care clinic, and must continue participation, or upon initial placement into a clinic.

PROCEDURES FOR INPATIENT MORBIDITY AND PROCEDURES CLASSIFICATION

FORM:

For inmates placed in inpatient status in Medical Referral Centers (MRC) or community hospitals (CH) the following procedures will be used to capture morbidity statistics. The

Outpatient Classification forms will NOT be used for inpatients with the exception of infectious diseases, (i.e., TB testing, HIV classification, etc.).

SENSITIVE MEDICAL DATA CATEGORY Page 1-18

BOP Medical Referral Center

a. Information for data entry will be obtained from the medical record.

b. The effective date and time of visit will be the date and time the inmate is discharged from inpatient status.

c. The type of provider code for Medical Referral Center is

MR.

d. The diagnoses and procedures the inpatient had when discharged will be entered on SENTRY using the PP34 transaction.

The physicians will list all discharge diagnoses and procedures on the inpatient cover sheet (also known as the face sheet) for all BOP Medical Referral Center inpatient stays. The discharge diagnoses and procedures will be coded using the specific ICD-9-CM. Inpatient coding includes all ICD-9-CM codes.

e. Inmates at Medical Referral Centers in inpatient status should have PPD testing, mammogram, PAP, HIV classification, annual chest x-ray, and HIV testing entered as appropriate. The entries should not wait until the time of discharge for these categories.

Community Hospitals

a. Information for data entry may be obtained from the bill. To expedite data entry the HSA should designate an individual to monitor bills and from them complete the Inpatient Morbidity and Procedures Classification form.

b. The effective date and time of visit will be the date and time the inmate is discharged from the community hospital.

c. The type of provider code for community hospital is CH.

d. The diagnoses and procedures the inpatient had when discharged will be entered on SENTRY using the PP34 transaction.

Appropriate records, for example DRG face sheet or discharge summary, should be obtained from the community hospital to permit full coding of the diagnoses and procedures. The discharge diagnoses and procedures will be coded using the specific ICD-9- CM code.

e. Procedures, both diagnostic and surgical, will be entered into the Sensitive Medical Data (SMD) system.

PROCEDURES FOR HIV TESTING, RISK, AND CLASSIFICATION CODING. The SENTRY SMD category also allows for the reporting of HIV testing, HIV risk, and CDC HIV classification. The Outpatient Morbidity Classification form will be used for data collection for HIV cases using the following procedures for reporting HIV related morbidity data.

SENSITIVE MEDICAL DATA CATEGORY Page 1-19

HIV Testing. Every inmate tested for HIV must have an SMD assignment entered into SENTRY. Inmates on admission will automatically receive the assignment of NOT TESTED, therefore, you will not need to enter this assignment. The effective date and time entered into SENTRY will be the date and time of specimen collection. When an inmate is tested, one of the testing assignments listed below will replace the NOT TESTED assignment. An inmate may have one and only one TESTING assignment. For example, when an inmate is retested, you must replace the current assignment with the assignment and current test date. The provider who sees the patient for the HIV testing will complete the Outpatient Morbidity Classification form.

Testing assignments are:

Description Assignment Code

CLINICAL/VOLUNTARY HVTSTCV

NEW COMMITMENT HVTSTNC

NEW COMMIT RETEST RETEST

RANDOM SAMPLE RANDOM

PRE-RELEASE RELEASE

DESCRIPTIONS.

Clinical/Voluntary: Enter for all inmates tested because of clinical indications based on the inmate’s medical history or clinical presentation; and/or in cases in which the inmate requests testing.

New Commitment: Enter for the subset of new BOP inmates selected for mandatory testing based on BOP policy.

New Commit Retest: Enter for the mandatory retests (every 6 months) of inmates newly committed and preselected for testing for surveillance purposes.

Random Test: Enter for all BOP inmates randomly pre-selected for testing for surveillance purposes.

Pre-release: Enter for the mandatory testing of inmates prior to release.

If the HIV test results are negative, no further entries are required.

HIV Risk Factors. Only inmates who have a confirmed positive test must be given a RISK assignment. The risk factor assignment will only be available in the inmate's historical record. Risk assignments are:

SENSITIVE MEDICAL DATA CATEGORY Page 1-20

Description Assignment Code

BISEXUAL BISEX

OCCUPATIONAL BLOOD CONTACT BLOOD C

BLOOD TRANSFUSION BLOOD T

HETEROSEXUAL HIGH RISK CONTACT HET CON

HOMOSEXUAL HOMOSEX

INJECTION DRUG USE IV DRUG

NO KNOWN RISK NO RISK

TATTOO (While Incarcerated) TATTOO

HIV Classification. Inmates who have a confirmed positive test result and a current RISK assignment must also have a CLASSIFICATION based on the presence of symptoms or AIDS conditions (A,B,C or D) and CD4= T-cell count (1,2,or 3). (SEE

PAGE 1-5 FOR FURTHER INSTRUCTIONS/DEFINITIONS).

Description Assignment Code Asymp High CD4 A1 Asymp Mod CD4 A2 Asymp Low CD4 A3 Symp High CD4 B1 Symp Mod CD4 B2 Symp Low CD4 B3 AIDS Cond High CD4 C1 AIDS Cond Mod CD4 C2 AIDS Cond Low CD4 C3 HIV+ Unclassified D1

CONDITIONS (Associated with HIV Infection/AIDS)

CANDIDIASIS ESOPHAGEAL 112.84Z

CERVICAL CA (INVASIVE) 180.9Z

COCCIDIOIDOMYCOSIS (EXTRA PULM) 114.9Z

CRYPTOCOCCOSES (EXTRA PULM) 117.5Z

CRYPTOSPORIDIOSIS (CHRONIC) 007.4Z

CMV RETINITIS (OR ORGANS OTHER THAN LIVER/NODES 078.5Z

ENCEPHALOPATHY (HIV) 348.3Z

HERPES SIMPLEX (>1 MONTH) 054.9Z

HISTOPLASMOSIS (EXTRA PULM) 115.9Z

ISOSPORIASIS 007.2Z

KAPOSI'S SARCOMA 176.9Z

LYMPHOMA…