Antimicrobial Resistance: A Growing Threat

Know your role as the CDC calls for data.

By Shelley C. Safian, PhD, CPC-H, CPC-I, CCS-P
Antimicrobial resistance is not a new concern, but the Centers for Disease Control and Prevention (CDC) recently issued a renewed warning for this health threat, along with a request for data. Because coders are the keepers of this data, you should pay attention to the issue.

An Old Problem, Renewed

In 1928, bacteriologist Alexander Fleming discovered an antibacterial action in a mold that had grown on a culture plate of staphylococci bacteria (a serious threat, and often a life-threatening human infection). The mold became known as “penicillin,” and it was a medical breakthrough.
The first antibiotics were prescribed in the late 1930s. The number of deaths caused by bacterial infection dropped dramatically. Life expectancy increased by at least eight years between 1944 and 1972—an increase largely credited to the use of antibiotics. The healthcare industry believed that bacterial infections were a thing of the past. In 1969, then-U.S. Surgeon General William Stuart testified to Congress that the time had come to “close the books on infectious diseases.”
Little did we know that less than 50 years after the testimony we’d be battling antimicrobial resistance (AMR). The World Health Organization defines this phenomenon as the “… resistance of a micro-organism to an antimicrobial medicine to which it was originally sensitive.” Here we are, 85 years after Fleming’s discovery, and the overarching benefits of this incredible breakthrough are dwindling.

Overuse, Evolving Bugs, and the Cost

One of the biggest reasons antibiotics have lost effectiveness is improper use, or overuse. For instance, research has shown and estimated that 50 percent of the time antibiotics are prescribed for patients who do not need them.
The natural phenomenon of adaptation is another reason why antimicrobial drugs are no longer working. Biologists call this “adaptive immunity.” The concept is similar to the process of vaccinations affording a patient ultimate resistance to the effects of a specific pathogen. Only, in this case, it’s the pathogen gaining the immunity.
A third underlying cause of AMR is ineffective infection control and prevention in healthcare facilities. For example, it can be a challenge to get all staff members to understand the importance of washing their hands to reduce spreading pathogens too small to see or feel. The invisibility of these tiny organisms makes it difficult for some individuals to believe they exist.
There’s also an increasing rate of healthcare-associated infections (HAI) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycinor multidrug-resistant enterococci gram-negative bacteria. HAIs occur in hospitals, outpatient clinics, nursing homes, and other healthcare provider locations—they are not just the concern of inpatient acute care facilities.
These fortified pathogens are costing us billions of dollars—an estimated $20 billion in excess direct healthcare costs—for the extended care that’s now required for patients who previously would have been cured by a 10-day course of antibiotics. The cost difference is significant, even at a small level. For example, one Amoxil® can cost approximately 40 cents; a single Zithromax® costs maybe 50 cents; but, ciprofloxacin (Cipro®)—the drug still effective in many of these patients—is approximately $3.60 per pill.
The patients with the greatest risk of contracting an AMR infection are seen every day in every type of facility: patients with malignancies undergoing chemotherapy; those who have recently had complex surgery; those suffering with rheumatoid arthritis (RA); those with end-stage renal disease (ESRD) undergoing regular dialysis; and patients who have recently received an organ or bone marrow transplant.

Coding for AMRs

The CDC identified three pathogens as urgent threats in their publication, Antibiotic Resistance Threats in the United States, 2013: Clostridium difficile (C. diff), carbapenem-resistant Enterobacteriaceae, and drug-resistant Neisseria gonorrhoeae. Let’s look at some details about these three urgent concerns.
Clostridium difficile (C. diff)
C. diff is a spore-forming, gram-positive anaerobic bacillus that causes life-threatening diarrhea and has been documented as causing about 250,000 infections each year, which have resulted in about 14,000 deaths. Of those patients aged 65 and older infected with C. diff, more than 90 percent died. In total, C. diff costs us an estimated $1 billion in excess healthcare costs. At greatest risk for contracting C. diff are hospitalized patients, those who have been recently hospitalized, and those who have recently received medical care with a course of antibiotic therapy.
The CDC is calling for more data as they track these AMRs. ICD-9-CM and ICD-10-CM both give us the tools to collect and submit these details. For example, these codes may be reported for a patient with C. diff who is not responding to antibiotics:

V09.51   Infection with microorganisms resistant to multiple quinolones and fluoroquinolones Z16.23       Resistance to quinolones and fluoroquinolonesZ16.24       Resistance to multiple antibiotics

Carbapenem-resistant Enterobacteriaceae (CRE)
CRE refers to a collection of microorganisms that have developed resistance to antibiotics. This grouping, or family, includes Klebsiella species and Escherichia coli (E. coli). Carbapenem antibiotics are beta-lactam antibiotics used as a last resort for many bacterial infections (brand names include Invanz®, Primaxin®, and Merrem®); however, increased resistance to these antibiotics has made them virtually ineffective.
Klebsiella pneumoniae carbapenemase (KPC) and New Delhi Metallo-beta-lactamase (NDM), types of CRE, are enzymes responsible for rendering carbapenems ineffective. CRE cause a variety of diseases, ranging from pneumonia to urinary tract infections to serious bloodstream or wound infections. Patients who are ill, exposed to hospital environments, and in long-term care facilities are most susceptible to CRE infection.
ICD-9-CM and ICD-10-CM codes include:

V09.1           Infection with microoganisms resistant to cephalosporins and other B-lactam antibiotics Z16.19          Resistance to other specified beta lactam antibiotics

Neisseria gonorrhoeae
Gonorrhea is caused by the Neisseria gonorrhoeae bacteria and is most often transmitted by sexual contact. This microorganism replicates easily in the warm, moist areas of the reproductive tract, as well as in the mouth, throat, eyes, and anus. Approximately 30 percent of gonorrhea infections are found to be drug resistant, and often, patients infected with drug-resistant Neisseria gonorrhoeae do not exhibit any signs or symptoms. This disease can have long lasting effects on the patient, including pelvic inflammatory disease that can result in infertility in women; and epididymitis (an inflammation of the structure within the testis that stores sperm and transports the sperm to the vas deferens) in men. A patient who has contracted gonorrhea is more susceptible to contracting the human immunodeficiency virus (HIV).
ICD-9-CM and ICD-10-CM codes include:

V09.1           Infection with microorganisms resistant to cephalosporins and other B-lactam antibiotics Z16.19          Resistance to other specified beta lactam antibiotics (resistance to cephalosporins)
V09.2           Infection with microorganisms resistant to macrolidesV09.3           Infection with microorganisms resistant to tetracyclines Z16.29          Resistance to other single specified antibiotic (resistance to macrolides) (resistance to tetracyclines)

The concept of healthcare-acquired infection contradicts the reasons healthcare exists. The business of healthcare facilities is to keep patients healthy and to make them healthy when they are ill. Physician offices, acute care hospitals, nursing homes, etc., all must take the steps necessary to ensure care does not result in patient harm.

Benefit by Playing Your Part in the Plan

The CDC’s plan to decrease incidents of AMR infection includes improved surveillance of patients throughout the United States. At the top of this list is the need to collect complete, quality data by reporting the prevalence and the incidence of AMR infections. They also need us to improve reporting of antibiotic use and to encourage advanced molecular detection technology use so physicians can confirm diagnoses (and patients can receive effective treatment sooner).
The next part of the CDC’s plan is right in our wheelhouse: Improved tracking of antibiotic-resistant infections, risk factors, and the underlying causes of the infections. Professional coders know the value of quality data. The CDC is reaching out to you to submit data so they are able to track and benchmark resistance to antibiotics in patients with bacterial infections and to track patient antibiotic use.
The secondary benefit of collecting this data stays with the facility itself. Analysis of your own data with regard to patients diagnosed with AMR infection can enlighten and provide direction for internal improvements to current prevention programs.
There are many other benefits to what the CDC calls “antibiotic stewardship,” as well. Increased patient outcomes, decreased costs of patient care, and reduced hospital stays are all excellent reasons to implement this reporting program.

Shelley C. Safian, PhD, CPC-H, CPC-I, CCS-P, is an ICD-10-CM/PCS trainer and a consultant for outpatient facilities focusing on optimal reimbursement and compliance, as well as the transition to ICD-10-CM. She has been teaching coding and health information management for more than a decade. She is a member of the Orlando, Fla., local chapter.
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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