Q&A: Appropriately reporting symptoms

Q: A patient with documented acute respiratory failure, could have both confusion and somnolence, but should both confusion and somnolence be coded? When should the symptoms be coded? For example, with a patient who has abdominal pain with nausea and vomiting, should the nausea and vomiting be coded?

A: It comes down to the interrelation between symptoms and what could reasonably be expected to be integral. Confusion and somnolence are probably intrinsic to respiratory failure as severe hypoxia/hypercapnia will do all that and even make a patient lose consciousness completely. Again, if it appears the confusion and/or somnolence is not related to the respiratory failure, then the coder may report the codes. But, this could only be done with very clear physician documentation.  Let’s look at a couple examples.

•  “Patient presents with somnolence, confusion, shortness of breath, and is found to be in respiratory failure.” In this case, only report respiratory failure.
•  “Patient presents with respiratory failure and is discovered to have confusion and somnolence possibly related to seizure activity. However, seizure activity was ruled out via EEG, consider hypoglycemia versus TIA.”

In this second example, the physician is clearly not relating the confusion and somnolence to the respiratory failure. The physician appears to be considering neurological causes but neurological causes are ruled out. If the work-up continues to be negative, it might be appropriate to actually report the codes for the confusion and somnolence of suspected neuro or metabolic cause where all the work up was negative and you are only left with the symptoms. This might also be a legitimate case of multifactorial or metabolic encephalopathy (due to a combination of hypoglycemia, hypoxia, and other disease processes).

Critical thinking on the part of the CDI specialist and coder is, well, critical (to try and get this as accurate as possible).

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.