Case studies offer tips for principal diagnosis assignments

Ideally, documentation of each patient encounter should include the following:

This includes a ­thorough review of progress notes, the ­history and physical, ­consultations, physician orders, and any other reports designed to capture diagnostic information.

 

The UHDDS defines “principal diagnosis” as the condition established after study to be chiefly responsible for occasioning a patient’s admission to the hospital.

 

The term “after study” can sometimes confuse coding professionals, says Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, an AHIMA-approved ICD-10-CM/PCS trainer in California with more than 30 years of HIM experience. “You really need to look at a lot of information,” she says. “You need to see what [the physician] is studying. You need to look at what happened after the patient was admitted, what the tests were, and what the focus was.”

 

Consider this scenario. A 72-year-old woman ­presents to the ED after several of her fingers were caught in a car door while she was closing it. A clinician cleans the wounds, applies antibiotic cream, and wraps the finger; x-rays show that no fracture is present. The patient complains of anxiety and shortness of breath while leaving the hospital, and a nurse notes that she looks pale and diaphoretic. Oxygen is administered, and the patient is placed on a stretcher. An EKG shows old changes with normal rhythm. Her troponin I is 3.22.

 

Patients often present to the ED with certain complaints, and then during the visit, physicians ­identify a different problem for which the patients are subsequently ­admitted, says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.

 

In the previous scenario, the patient presented for treatment of her wounds, but she ultimately was admitted because of elevated ­cardiac ­enzymes and classic presentation of myocardial ­infarction (particularly in female patients), he says. After study, it may be documented that the patient did, in fact, suffer a heart attack.

 

Although it’s rare, symptoms can be the principal ­diagnosis, says Bryant. “It’s not very common because we usually get a definitive diagnostic statement, but we can on occasion have a symptom end up being the ­principal diagnosis,” she says.

 

The ICD-9-CM Official Guidelines for Coding and Reporting state that if a physician’s diagnostic statement identifies a symptom followed by contrasting/comparative diagnoses, coders should sequence the symptom first.

 

More often, patients present with symptoms that lead to a preliminary diagnosis that leads to a presumptive diagnosis followed by an actual diagnosis, says Gold.

 

Consider this scenario. A 73-year-old woman ­presents to the ED after becoming faint and dizzy while ­shopping. She receives oxygen, and an EKG shows no acute ­changes. Her physical exam is clear regarding neurological, heart, lungs, and other body systems, with the exception of conjunctivae, which are pale. Hemoglobin is 7.6 with microcytic (small), hypochromic (pale) red cells. Stool is hemoccult positive. Patient is admitted for monitoring of heart and oxygen saturations and neurologic evaluations to determine whether she suffered a stroke. A GI consultation leads to a colonoscopy, which shows a large, sessile lesion, likely colon cancer, in the cecum. The patient undergoes bowel prep and is scheduled for surgery.

 

In this case, although the patient presents with faintness and dizziness, colon cancer is the principal diagnosis, says Gold. The GI consultation is an important part of documentation that coders should review, he says.

 

Coding conventions in ICD-9-CM volumes 1 and 2 take priority over official coding guidelines, says ­Bryant. This means coders should be on the lookout for ­includes and excludes notes, inclusion terms, code also notes, and any etiology/manifestation codes with special ­sequencing rules.

 

“If you’re not looking at the details around a code that you’re selecting … you could end up with the wrong principal diagnosis code and certainly wrong ­secondary diagnoses as well,” says Bryant.

  

The circumstances of an admission always govern selection of the principal diagnosis, says Bryant. They are particularly important when two or more interrelated conditions each potentially meet the definition of principal diagnosis. Coders must review the circumstan­ces of an admission, the therapy provided, the Tabular List, and the Alphabetic Index. If these references don’t provide any additional guidance, coders may sequence either condition as the principal diagnosis.

 

Coders don’t always fully investigate whether both conditions truly meet the definition of principal diagnosis, says Bryant. “Don’t leave out the circumstances of the admission,” she says. “You can end up with the wrong principal diagnosis, the wrong MS-DRG, and ultimately the wrong payment, which leaves you open for scrutiny.”

 

Consider this scenario. A 73-year-old woman presents to the ED after her daughter finds her on the bathroom floor and rushes her to the hospital. The patient has no symptoms or signs of stroke, heart attack, or acute respiratory disease. No significant arrhythmias or blocks are seen on the EKG, and troponin levels are normal. She has Type 2 controlled diabetes and a history of an AMI with CABG three years ago. She had a stent inserted in February. She is diagnosed with ischemic cardiomyopathy with ejection fraction of 35%. Urinalysis shows a white blood cell count of 40–60/hpf and gram-negative rods. Patient is admitted to the hospital and is started on Cipro® by mouth.

 

In this scenario, the asymptomatic urinary tract infection (UTI) is an incidental finding, says Gold. The patient receives treatment ­(Cipro), which is the same medication that she would have received in a physician’s office from where she wouldn’t have been admitted to the hospital, he says.

 

Bryant agrees. The fact that a patient takes ­Cipro orally and not via an IV is often an indication that a UTI isn’t severe enough to warrant inpatient ­admission, she says.

 

Thus, coders must continue to search the documentation to determine the diagnosis after workup (or the sign/symptom) that is responsible for the patient’s fall and subsequent admission.

 

Consider the following. After workup, the patient is found to be significantly dehydrated. She hadn’t been eating or drinking well due to the fact that she has Alzheimer’s disease. Studies find that she has rhabdo­myolysis and acute kidney injury.

 

Thus, the principal diagnosis is acute kidney injury due to dehydration, says Gold. “Just because there was a urinalysis that was identified as abnormal in the ED—and the patient was started on treatment—don’t jump to the conclusion that it’s a potential co-principal diagnosis,” he says. Conversely, if the physician never determines why the patient fell, then coders should report the sign or symptom as the principal diagnosis.

 

Coders generally should exercise care when assigning codes for complications, particularly when assigning complications as a principal diagnosis, says Gold.

 

Consider this scenario. A 46-year-old male is seen for same-day surgery for a left indirect inguinal hernia repair without mesh. During the procedure, significant bleeding occurs with a finding of a laceration of the common femoral vein. Clamps are applied after opening the groin. Three units of blood are lost, but the patient is stabilized with Ringer’s solution. The vein is repaired and the hernia fixed, and the patient is admitted to the hospital.

 

Although the patient presents to same-day surgery for the hernia repair, the hemorrhagic complication of the procedure is the reason for the actual admission, says Gold.

 

“Whether the patient did or did not have anemia due to acute blood loss may be something to consider through further review of the record, but certainly the reason for inpatient stay was the hemorrhage and not the hernia.”

 

Editor’s Note: The content in this article was originally presented during HCPro’s audio conference “Principles of Principal Diagnosis Selection: Compliance Through Guidelines and Case Scenarios.” This article was originally published in Briefings on Coding Compliance Strategies.