Q&A: Atelectasis query for secondary diagnosis

Q: When atelectasis is noted on an ancillary test such as a CT-scan of the abdomen or chest x-ray can nursing documentation of turning, coughing, and deep breathing considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?

A: In order to answer your question more information surrounding the circumstances of the encounter would be required. Atelectasis is usually considered an integral condition when it occurs following surgery because the turning, coughing, and deep breathing is typically routine protocol for this type of patient.

There are specific guidelines for coding conditions that may be an integral part of a disease process. If the condition is routinely associated with the disease process or procedure and no additional monitoring or treatment is ordered to evaluate the condition then the additional code would not be separately assigned. If the attending provider orders additional monitoring or treatment to evaluate the condition, such as continued x-rays to monitor the progress and resolution of the Atelectasis, it would be a reportable condition. Some other examples of integral conditions would be an “ileus” following bowel surgery, or “pleural effusions” in a patient with congestive heart failure that is not aggressively treated.

Before we assign a code for a secondary diagnoses, we need to ask ourselves, does it meet UHDDS criteria for a secondary diagnoses? The CDI specialist needs to determine if the condition required:

• Clinical evaluation
• Therapeutic treatment or a diagnostic procedures
• An extended length of stay
• Increased nursing care and/or monitoring
• Is it supported by at least one clinical indicator

Additionally, consider whether:

• Other providers would arrive at the same conclusion/make the same diagnosis?
• The diagnosis integral to another condition?
• This diagnosis relates to this episode of care?
• The diagnosis was documented by a treating provider?
• There is a conflict with the attending provider?

Since abnormal findings (laboratory, x-ray, pathology, and other diagnostic results) are not coded and reported unless the attending provider indicates their clinical significance you first need to ensure the finding is a reportable diagnosis before you can query for the associated diagnosis to be added. If findings are outside the normal range and the attending has ordered other tests to evaluate the condition or prescribed treatment, it would be appropriate to query the physician to have the clinical significance clarified and diagnosis added.

Editor's note: Sharme Brodie, RN, CCDS, a CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.