Avoid Sequencing Oversights for Profit

 

Every so often I come across some coding issues that bring to mind other coding concerns I've found in the past. The following are three different scenarios that demonstrate how easy it may be to misinterpret clinical documentation to financial benefit of the facility.

 

A baby arrives at the hospital with weight loss.  The baby can’t keep anything down.  The pediatrician and the baby’s mother tried various dietary modifications, size of feeding, various changes in formula—they eliminated breast milk, tried soy products, fed the baby small amounts of food frequently, fed the baby large amounts a few times a day, added a little farina to thicken the feeding.  Nothing worked.  The child’s weight continued to decrease as the baby became more malnourished. Eventually, the baby became sleepy, and weak, and dehydrated. 

 

The child was admitted to the hospital for workup. IV fluids were administered and parenteral nutrition started to provide the baby with some caloric intake.  Pediatric GI studies showed a significant sliding hiatal hernia and the baby underwent Nissen fundoplication.  Success!  Feeds were retained, the patient started gaining weight, all was well. The baby was discharged. 

 

Coders evaluated the chart and dehydration 276.51 and malnutrition 263.9 were assigned as the first two diagnoses with hiatal hernia 750.6 with gastroesophageal reflux 530.81 as subsequent diagnostic information.  The result was DRG 982, Extensive OR Procedure Unrelated to Principal Diagnosis with CC. 

 

A typical CDI specialist might think this scenario played out appropriately. Cool, right?  We know DRG 982 is a good paying DRG (with a relative weight of 2.8954).  So, it must right. After all, that’s what brought the patient into the hospital, right?

 

Wrong.

 

The malnutrition and the dehydration were symptoms, manifestations of a disease process. After workup, treating physicians discovered the hiatal hernia with significant esophageal reflux, so that became the diagnosis after workup and must be considered the principal diagnosis. 

 

Re-sequencing the diagnoses properly, then, the DRG assignment is now 327, Stomach. Esophageal and Duodenal Procedures with CC (with a relative weight of 2.7062).  Sure, it’s a DRG that reimburses less, but clinically speaking it is the correct DRG.

 

If you consider the co-principal diagnosis argument and the fact that you can sequence either first, the following concepts apply:

This case recalls another situation that I’ve seen many times in many places.  An elderly lady shopping at WalMart, became weak and dizzy, and almost passed out but fell against the Charmin display, knocking over the stacks of toilet paper. 

 

An assistant manager called 911 and the emergency personnel arrived. They applied oxygen, took her vital signs (tachycardia rate of 124/minute, slight tachypnea with breathing at 22 respirations a minute, blood pressure slightly low at 98/60).  They transported her to the ER where she was admitted. The EKG monitor showed some old ST-T wave changes. Her oxygen saturation was 88% on room air and her vital signs were consistent with what the emergency transport had found. 

 

The physician in the ER thought she appeared pale and ordered a CBC and orthostatic vital signs to be taken.  Indeed, it was found that she had a rise in pulse rate and a slight drop in blood pressure in hanging from lying supine to sitting, from sitting to standing and she became dizzy again.  The physician wrote “orthostatic hypotension.”  The CBC came back with a hemoglobin of 6.8 and hematocrit of 22.  The cells were hypochromic (pale) and microcytic (small).  Immediately, the ED physician ordered a stool for hemoccult and had the patient admitted with diagnoses of:

Workup proceeded in the hospital with upper gastrointestinal endoscopy and colonoscopy. Lo and behold, a relatively large, fungating, bloody sessile mass was found in the cecum with no signs of disease in the liver on liver scan.  The patient was prepped for surgery, given a few units of packed cells to bump the hemoglobin and underwent an uneventful lap assisted right hemicolectomy.  She was advanced in diet and discharged.  Pathology showed adenocarcinoma of the cecum with no positive nodes in the mesentery.

 

The coding team receives the medical record. Hum.  Such a conundrum. We have syncope 780.2, orthostatic hypotension 458.0 and anemia 285.9.  Then we add the right hemicolectomy and, wow,  DRG 264 Other OR Procedures for Circulatory Disorders with the syncope as principal which has a relative weight of 2.5087, same with the orthostatic hypotension first, but then there’s DRG 982 Extensive OR Procedure Unrelated to Admitting Diagnosis (2.7062) when we sequence the anemia first and follow that with the 154.0 for the cancer. That must be it, right?

 

Wrong again.

 

This is yet another case in which the patient’s presentation represented symptoms of the disease process which, after work up, turned out to be the malignant neoplasm of the colon. It was chronic blood loss from that malignancy that caused the patient’s anemia which caused the syncopal episode. 

 

The DRG assigned should be 331 Major Small and Large Bowel Procedures without MCC or CC (unless you can find one somewhere else) with a relative weight of 1.5952. 

 

Why? Because that’s the way it is.

 

Finally, selection of the proper procedure code can sometimes get one into trouble. There is a new code for the conversion of a percutaneous endoscopic gastrostomy (PEG) feeding tube to a transgastric percutaneous endoscopic jejunostomy (PEJ) feeding tube.  It had been, prior to October 1, 2008, that this description led to the assignment of an ICD-9-CM procedure code which made the procedure a major operating room procedure and led to the 981, 982, and 983 DRGs (formerly 468). 

 

Now, with the recognition that an anastomosis must be done endoscopically to justify a major operating room procedure, the code for the conversion of a PEG to a PEJ is no longer a procedure that affects DRG assignment. 

 

So be sure to read the operative note. If an anastomosis is done, then ICD-9-CM code 44.32 is justified and the procedure code affects the DRG.  But, even if the physician uses the phrase or abbreviation inappropriately for conversion of a PEG to a PEJ and calls it a PEGJ when no anastomosis was done, 46.32, a non-operating room procedure is warranted, and it would not affect the DRG assignment.

 

You have to consider truth, justice and the American way, and assign codes properly and according to the rules, even though there may be a financial incentive to “misinterpret” for the benefit of the bottom line.  And that’s where folks get into trouble. Now, you be careful out there.

Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician programs in clinical documentation improvement. The goals are data accuracy, profile management, and compliance for physicians and hospitals in the inpatient and outpatient arenas. Reach him by phone at 770/216-9691 or by e-mail at DCBAInc@cs.com.