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?

Diabetes Mellitus: is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia.  The 2 main categories of diabetes mellitus are: Type 1 - The body’s immune system destroys the beta cells within the pancreas, leading to an inability to produce insulin. Type 1 diabetes requires daily insulin therapy. Historically described as juvenile-onset diabetes. Accounts for less than 10% of all cases of diabetes mellitus. Type 2 - The body still produces insulin, but the body’s cells are unable to utilize the insulin efficiently, leading to insulin resistance. Liver and fat cells are inefficient at absorbing the insulin, resulting in higher glucose levels and increased insulin production. The pancreas loses the ability to produce adequate levels of insulin. May require insulin replacement. Hyperglycemia : Blood sugar > 140 mg/dL Provider documentation should clearly identify diabetes complications as “hypoglycemia” or “hyperglycemia” instead of “uncontrolled diabetes” to ensure accurate code assignment. Example: A patient with a history of type 2 diabetes was found to have blood sugars ranging from 150-220 mg/dL. The provider documents “uncontrolled diabetes” in the H&P. A query should be sent to clarify the diagnosis as “Diabetes mellitus type 2 with hyperglycemia” for accurate capture of the diagnosis. Diabetes mellitus type 2 with hyperglycemia is an Elixhauser variable and an HCC. Provider documentation should clearly differentiate POA status of DM with hyperglycemia when related complications are also documented, such as HHS or DKA. Example: When a provider documents hyperglycemia as POA and a second provider later determines the patient has DKA or HHS. CDI should send a query for clarification of the POA status of documented conditions. CDI would also send a clinical validation query if HHS or DKA is lacking sufficient clinical evidence to support the diagnosis. Provider documentation should clarify if “diabetes type 2 with hyperglycemia” is a complication of a medical treatment to capture appropriate code assignment. Example: A patient with pre-existing type 2 diabetes mellitus presented with hyperglycemia, and the provider notes hyperglycemia is likely secondary to autoimmune DM, which occurred following immunotherapy initiation. Assign codes for Diabetes type 2 with hyperglycemia, and an additional code for the adverse effect of antineoplastic and immunosuppressive drugs. If there is any question of a cause-and-effect relationship, a query would be warranted for clarification. In the OP arena, look for an A1c > 7 to consider a query for control status, unless the provider documents a specific goal in the visit note i.e. A1c goal is < 7.5, etc. NCQA / HEDIS Comprehensive Diabetes Care measure looks for HbA1c control (<8.0%). See below:

Coming FY 2025 ICD-10 is expanding subcategory E10 to identify stages of Presymptomatic Diabetes Mellitus Come October 1, we will now be able to identify diabetes at earlier presymptomatic stages. ICD -10 is expanding subcategory E10 to identify stage1 and 2 presymptomatic diabetes. Type 1 diabetes can now be most accurately understood as a disease that progresses in three distinct stages. STAGE 1 is the start of type 1 diabetes. Individuals test positive for two or more diabetes-related autoantibodies. The immune system has already begun attacking the insulin-producing beta cells, although there are no symptoms and blood sugar remains normal. 1 STAGE 2 , like stage 1, includes individuals who have two or more diabetes-related autoantibodies, but now, blood sugar levels have become abnormal due to increasing loss of beta cells. There are still no symptoms. 2 STAGE 3 is when clinical diagnosis typically takes place. By this time, there is significant beta cell loss and individuals generally show common symptoms of type 1 diabetes, which include frequent urination, excessive thirst, weight loss, and fatigue. 3 1,2,3 Type 1 diabetes staging classification opens door for intervention | TRIALNET Type 1 Diabetes TrialNet