Q: In regards to the Coding Guideline that states, "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 guideline does not provide sequencing direction, any one of the diagnoses may be sequenced first." Would it be appropriate to code the diagnosis that is more resource intensive, higher weighted DRG as the principal diagnosis? This question comes up when consultants are doing coding reviews when the facility has coded the diagnosis with the lower weighted DRG as the principal diagnosis. Even though either diagnosis can be selected as the principal diagnosis, would it be appropriate to recommend that the DRG that is the most resource intensive be coded as the principal in order for the facility to receive proper payment for that visit?
A: The answer to your question is "yes." The guideline states that when two or more criteria equally meet the definition of principal diagnosis...meaning that both conditions were present on admission and necessitated admission, either one can be sequenced first. Some common examples might be CHF with pneumonia, dehydration with pneumonia, etc. I think that the hospital can select the more resource intensive, higher weighted one when that diagnosis in and of itself meets the definition of PDX. I am sure it is standard practice. I always go back to the H&P and ED notes to make sure both conditions were present and necessitated admission. When I am satisfied with that, I go to the higher weighted condition.
Patricia Arvantides, RHIA
Q: A patient has a PAC for dialysis, dropped the port on the floor and did not clean the port, just recapped the port. Then was admitted with infection with peritonitis. Would 999.3, complication of medical care be coded because port was not cleaned or 996.68, infection due to dialysis cath, be coded. The PAC was contaminated because the patient did not clean it before recapping it.
A: Based on the specifics of your question, the appropriate diagnosis is 996.68, Infection due to peritoneal dialysis catheter. This code is most specific in detailing the mechanism of infection, infection due to the presence of a catheter. Take a look at the heading under the 999 series; "Complication of medical care, Not elsewhere classified." The coder series 999 includes complications, not elsewhere classified of peritoneal dialysis but excludes specified complications classified elsewhere. The bottom line is that the peritonitis infection is due to the PAC catheter and there exists a specific code that best represents this clinical scenario.
Just a refresher on NEC- Not Elsewhere Classified. This term implies that the diagnostic statement supplied by the physician is specific, yet there is no particular ICD-9 code that best represents the diagnosis in question. Hence, the rationale for assigning a diagnosis to an "NEC" category. In the instance above, the specificity of the diagnostic statement permits assignment of a code other than an NEC code. The fact that the patient's own attention to the PAC contributed to the infection is not of material significance from a coding perspective. Witness a patient who develops a UTI from aseptic handling technique of an indwelling Foley catheter. The correct code assigned is 996.64, Infection due to indwelling urinary catheter. It helps to keep a clinical focus when contemplating assignment of an ICD-9 code. The peritonitis is due to the presence of the catheter and not a complication of medical care.
Glenn Krauss, RHIA, CCS, CCS-P
Q: A patient has a cardiac cath and the report states either "non-obstructive CAD" or "hyperkiniesia" or "no diffuse irregularities" or "no significant CAD." Do you code chest pain syndrome (786.59) or CAD (41400/41401) for any of those statements? Patient will either come in with chest pain with or without hx of CAD.
A: This is a scenario that coders are commonly faced with in reviewing a heart cath patient record. If the diagnosis of conclusion after the heart cath is "nonobstructive CAD" or any of the other diagnoses that you referred to in your initial question, clinically the cardiologist is stating that the patient does have some degree of coronary artery disease. However, the degree of coronary artery disease is insignificant, with the disease not a causative factor in the patient's chest pain. Based on your question and in this instance, the appropriate sequencing of diagnosis would be the chest pain (786.59) as principal diagnosis and the CAD (414.0X) as secondary.
Glenn Krauss, RHIA, CCS, CCS-P
Q: If the patient is admitted for physical therapy for neck pain consistent with cervical spondylosis, Medicare will not pay if we code it with V57.1 and721.0. Is it appropriate to code the symptoms, which would be then V57.1 and 723.1?Deborah Grider, CMA, CPC, CPC-H, CCS-P, CCP
A: ICD-9-CM Code 721.0 is not listed as an approved diagnosis for physical therapy based on Medicare's National Policy. CPT Code 723.1, Cervicalgia is on the list of acceptable codes for physical therapy along with V57.1. Only signs and/or symptoms should be coded if a definitive diagnosis is not available for outpatient services. Also, I would recommend checking the medical policy for the Medicare Fiscal Intermediary in your area for specific guidelines and criteria for billing Medicare for physical therapy. You will find acceptable modalities, CPT codes approved along with diagnoses, medical necessity policy and documentation requirements.
Q: I have an 88-year-old patient that is admitted for pneumonia. The patient was here for 17 days. It was coded as an 89, but now on our second level review, we are wondering if it should have been a DRG 79. Are there criteria to be met to code a DRG 79 just by the thrust of the treatment? Are there guidelines I can follow for the difference between the two?
A: General coding guidelines state to query the physician for clarification when chart documentation is unclear or contradictory. It is the "thrust" of the attending physician's documentation as to the treatment rendered and the subsequent diagnoses that will enable the coding to be as specific as possible and the DRG assignment to be appropriate for reimbursement.
I would suggest that the coding staff will benefit from an internal in-service as to the diagnosis and treatment of pneumonia so they can formulate the physician queries appropriately. I have found that in addition to the medical staff, hospital professionals in Infection Control, QA, Utilization Management and Respiratory Services can provide information, resources and training in this area for diagnosis and treatment. Also, in return, providing information to the medical and ancillary staff the specifics regarding the coding of pneumonia as it pertains to the variety of code categories and subcategories, the guidelines for principal diagnosis and the related DRG assignments that are a focus of OIG review will encourage quality chart documentation and assist the coding staff to meet their requirements for coding. Encouraging the best specific documentation will help provide better discharge data and information for outcome studies. In addition, there are also AHA Coding Clinic references and AHIMA has previously offered conferences on the subject of pneumonia coding.
Kathy Myrick, RHIT, CCS
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