This is the final part of a three part series in which we address how coders can better interact with Clinical Documentation Integrity (CDI) professionals. In this part, we provide an actual example of an effective communication response to CDI.
Principal Diagnosis Mismatch Communication Example
The CDI professional has chosen E87.6, hypokalemia as the principal diagnosis which leads to DRG 640. This is a DRG Mismatch. Coder’s diagnosis is A41.9, for neutropenic sepsis leading to DRG 871. There were queries on the record by CDI that were not answered by the physician.
This is an example of what a good communication back to the CDI professional would look like, based on an actual mismatch case received by a coder:
“Dear CDI professional (insert actual name of person):
I have chosen A41.9, sepsis as the principal diagnosis for neutropenic sepsis which leads to DRG 871. Neutropenic sepsis was the most resource intense DRG requiring IV antibiotics throughout the hospitalization and appeared to be the main focus after the potassium improved shortly after admission. The patient came into the ER with vomiting and diarrhea, and unable to tolerate any oral meds including antibiotics and required IV access. There were multiple conditions considered upon inpatient admission including hypokalemia, dehydration due to low p.o. intake with suspicion of underlying infection. The physician ultimately diagnosed neutropenic sepsis, and clinical indicators do support that diagnosis (WBC 0.4, Neutropenia, Platelets 52 cells X 10^3/uL -LOW; underlying infection of UTI, immunocompromised state from breast cancer) and patient was aggressively treated with IV antibiotics. The patient was unable to fight the infection due to low neutrophils and thus developed neutropenic sepsis. This appeared to be the more acute condition for which the admission was focused upon. She did receive IV meds for hypokalemia, however under normal circumstances, potassium would be treated using oral medications if not for the sepsis and inability to tolerate p.o. meds. Potassium was 2.6 on admission and improved shortly after admission. So given the fact that multiple conditions were responsible for admission, I followed OCG section II guidelines for PDX selection”
Documentation:
Medical Decision Making: This is a 75-year-old female with a history of anxiety, hypertension, atrial fibrillation on anticoagulation, and recent diagnosis of breast cancer for which she was started on chemotherapy 5 days ago presenting to the ED with a complaint of vomiting and diarrhea over the past 24 hours.
Presumed diagnosis includes adverse effect of her chemo treatment that was recently started, occult infection, viral gastroenteritis
This establish IV access, obtain appropriate diagnostic labs, EKG, chest x-ray, labs and UA. Normal saline 1 L fluid bolus.
Addendum 1 5:50 PM in ED: I reviewed patient work-up in ED today she is found to be significantly neutropenic with a white blood cell count of 0.4. Chest x-ray shows no focality in keeping with pneumonia. However she is found to have a significant urinary tract infections forwhich she will be aggressively starting IV antibiotics at this time. Her metabolic derangements include a potassium of 2.6. Serum at Ca is 7.9. Thick acid is unremarkable. Her pH on her blood gases 7.49 with a PCO2 of 34. Her troponin is negligible. Flu testing is negative.
This patient will be admitted to the hospital given her inability to tolerate orals, dehydration, neutropenic, hypokalemic and a urinary tract infection inability to tolerate antibiotics orally.
Impression and Plan:
Impression
Diagnosis: Urinary tract infection,
immunocompromise,
hypokalemic,
dehydration.
Plan
Disposition: Admit: Time to Medical Unit.
History and Physical: Additional Info/ Background/history of present illness:
75-year-old female with past medical history of Anxiety , Atrial fibrillation , Breast cancer , Goiter, nodular , Hemangioma of liver , High blood pressure , Mild sleep apnea –
Recently diagnosed with recurrent breast cancer/metastasis and started on a new chemotherapy
Routine, comes in with nausea, vomiting and diarrhea with evidence of neutropenic sepsis.
Major medical issues at this time include the following:
- Neutropenic sepsis
- Metastatic breast cancer, status post chemotherapy
- Acute on chronic malnutrition
- Severe dehydration with hypokalemia
- Coagulopathy secondary to Pradaxa use
- Atrial fibrillation rapid ventricular response
PLAN :
Patient will be treated with broad-spectrum antibiotics as per the neutropenic sepsis pathway.
Options include IV cefepime versus IV Zosyn -likely source of her infection is urinary
Given her severe neutropenia with (ANC less than 200) -is at risk for fulminant sepsis.
Also she should get hematology/oncology consultation for Neulasta/Neupogen infusion
Progress Note:
Sepsis secondary to UTI in neutropenic patient: Tachycardic and leukopenic on presentation meeting sepsis criteria. She remains afebrile and asymptomatic
-Urine culture growing pansensitive e coli
-Status post ceftriaxone x1, continue cefepime
-Blood culture neg at 50 h
Patient was made DNR, refusing more chemotherapy and discharged to hospice.
AHA and Official advice reviewed:
Neutropenic sepsis Coding Clinic, Second Quarter 1996 Page: 6
Official Guidelines for Coding and Reporting Section II PDX selection, multiple conditions:
“The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
“C. Two or more diagnoses that equally meet the definition for principal diagnosis
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.”
Conclusion
As you can see above, the coder has provided the reasoning and documentation for their choice of principal diagnosis. This fully explains the coder’s position.
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.