CCS Prep

Understand the Coding and Sequencing Requirements of Dehydration, Hypovolemia

Dehydration and hypovolemia are very common diagnoses and will frequently increase reimbursement when assigned as a secondary diagnosis for inpatient Medicare admissions. Therefore, all coders and those sitting for the certified coding specialist (CCS) examination should be familiar on how to code these conditions as well as the sequencing requirements. Volume depletion refers to the depletion of total body water (dehydration) or the depletion of the blood volume (hypovolemia).

Dehydration (276.51) is a condition that results from the loss of water essential for normal body function. Vomiting, diarrhea, the use of diuretics, profuse sweating and decreased fluid intake can lead to dehydration. Signs and symptoms of dehydration include irritability; confusion; dizziness; weakness; anorexia; extreme thirst; fever; dry skin and mucous membranes; sunken eyeballs; poor skin turgor; decreased urine output; and increased heart rate with falling blood pressure. Confusion is one of the best indicators that dehydration has become severe. Very severe dehydration can lead to coma. The treatment for dehydration is the replacement of body fluids with oral fluid intake or IV fluid replacement.

Hypovolemia (276.52) is an abnormal decrease in blood volume or an abnormal decrease in the volume of blood plasma. Common causes of hypovolemia are dehydration, bleeding and drugs such as diuretics or vasodilators to treat hypertension. Signs and symptoms of hypovolemia include change in mental status; thirst; tachycardia; orthostatic hypotension; cool, pale skin; and weight loss. Laboratory tests indicative of hypovolemia include decreased hematocrit and hemoglobin if the patient is bleeding; elevated BUN; and increased urine specific gravity. Severe hypovolemia can lead to hypovolemic shock. The treatment for hypovolemia is to replace body fluids with fluids of the same concentration to avoid hypovolemic shock. Normal saline solution or lactated Ringer's solution are infused, with subsequent infusion of plasma proteins such as albumin. Blood transfusions when there is excessive bleeding may also be indicated.

Blood volume may be maintained despite dehydration, with fluid being pulled from other tissues. Conversely, hypovolemia may occur without dehydration, when third-spacing of fluids occurs in patients such as those with significant edema or ascites.

Coding Issues Related To Volume Depletion

Dehydration and hypovolemia (identified only as dehydration from this point forward) can be standalone conditions or can be caused by or associated with another condition as indicated above. When dehydration is associated with another condition it is often confusing to coders on how to sequence the codes. The determination of whether or not the dehydration should be assigned as the principal diagnosis depends on the circumstances of the admission and the judgment of the attending physician. Dehydration is listed first if it is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The documentation must indicate that dehydration requires inpatient management, and the treatment of the dehydration is the chief reason why the patient was admitted. When the condition causing the dehydration is also listed as a chief reason for the admission, then the condition after study to be causing the dehydration would be the principal diagnosis. If there is any doubt about the principal diagnosis, query the physician.

Dehydration and Gastroenteritis

If a patient is admitted with both dehydration and gastroenteritis it is important to verify which condition is responsible for the patient's admission to the hospital.

If the dehydration is mild and could have been treated on an outpatient basis and the reason necessitating inpatient admission is the acute gastroenteritis, then the gastroenteritis, 558.9, is assigned as the principal diagnosis. The dehydration, 276.51, is assigned as a secondary diagnosis.

If the reason for the admission is management of dehydration with IV fluids, but the gastroenteritis does not require inpatient evaluation or treatment, assign dehydration, 276.51, as principal diagnosis and the gastroenteritis, 558.9, as a secondary diagnosis.

Again, if there is any doubt as to which condition should be the principal diagnosis, the physician should be queried.

Dehydration and Acute Renal Failure

If a patient is admitted with acute renal failure secondary to dehydration and treated with IV fluids, the acute renal failure, 584.9, is sequenced first and dehydration, 276.51, is a secondary diagnosis.

In most instances IV hydration should correct acute renal failure and renal functions are followed with close monitoring of fluid intake and output. Hydration increases the intravascular volume and permits the kidneys to return to normal function. No further renal workup is necessary to validate acute renal failure as the principal diagnosis in this instance, according to Coding Clinic.

Dehydration Due to Malignancy

When the encounter is for the management of dehydration due to a malignancy and/or the therapy related to the malignancy, and only the dehydration is being treated, the dehydration is sequenced first, followed by the code(s) for the malignancy.

When reporting volume depletion due to chemotherapy, it is also important to report code E933.1, Drugs, medicinal and biological substances, causing adverse effects in therapeutic use, antineoplastic and immunosuppressive drugs.

It is important to remember that dehydration and hypovolemia codes should not be assigned based on an abnormal laboratory finding alone without seeking clarification from the physician.

On the other hand, when laboratory findings and other documentation in the medical record do not appear to validate a physician's diagnosis, the physician should also be questioned. In some instances a secondary diagnosis of dehydration is not supported by the laboratory and clinical findings.

Take the following quiz to test your knowledge of the guidelines:

1. A patient is admitted with a diagnosis of diarrhea with dehydration due to infectious gastroenteritis. The dehydration is treated with IV fluids and the diarrhea is treated with Kaopectate. How should this case be coded?

a. 008.8, 276.51

b. 009.0, 276.51, 787.91

c. 276.51, 008.8, 787.91

d. 276.51, 009.0

2. A patient with lung cancer is admitted to the hospital with syncope, vomiting, diarrhea and dehydration. After the workup; the physician documents adrenal tumors, which explain the patient's dehydration. The dehydration is treated with IV fluids but no treatment is given for adrenal metastasis. How should this case be coded?

a. 276.51, 198.7, 162.9

b. 198.7, 276.51, 162.9

c. 162.9, 198.7, 276.51

3. A patient with known HIV disease is admitted with diarrhea and dehydration. The patient is treated with IV fluids on admission. After the workup; it is determined that the dehydration is due to cryptosporidiosis. The diagnosis on discharge is cryptosporidiosis with dehydration secondary to HIV. How should this case be coded?

a. 042, 007.4, 276.51

b. 007.4, 042, 276.51

c. 276.51, 042, 007.4

d. 276.51, 007.4, 042, 787.91

This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services at HSS, an Ingenix company ( HSS specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic is published quarterly by the AHA. CPT is a registered trademark of the AMA.



Answers to CCS Prep!

1. d. Since Kaopectate is an oral antidiarrheal agent that may be administered on an outpatient basis, it appears that the dehydration necessitating IV fluids prompted the admission. In this instance, dehydration, 276.51, is the principal diagnosis. Infectious gastroenteritis, 009.0, is a secondary diagnosis. The diarrhea should not be assigned as a secondary diagnosis because it is a sign and symptom of the infectious gastroenteritis.

2. b. Adrenal metastasis, 198.7, is the condition after study to occasion the admission to the hospital; therefore it is assigned as the principal diagnosis. The dehydration, 276.51 is assigned next. The cancer of the lung, 162.9, is coded also. In this instance, during the hospitalization it was the CT scan that determined that the cause of the dehydration was the adrenal metastasis.

3. a. Assign code 042 for the HIV disease as the principal diagnosis, followed by 007.4, cryptosporidiosis. The workup during the hospital stay determined that the dehydration was due to the cryptosporidiosis, which is due to HIV. Dehydration, 276.51, is assigned as an additional secondary diagnosis.

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