Q&A: Determine the underlying cause of admission in elderly patients

Q: The majority of the admissions I am reviewing this week are for an elderly population. It seems that they all have the same admitting diagnoses: Failure to thrive (FTT), urinary tract infection (UTI), fever, dehydration, altered mental status (AMS). I am confused about how to identify the principle diagnosis in these cases, FTT or the UTI. Should I query for the underlying cause of the AMS?

A: Talk with case management or utilization review team members to better understand why these patients were approved as inpatient. Often these conditions can be treated in the outpatient setting. You don’t want to be adversarial, but sometimes providers don’t document the complete picture so it can be helpful to ask why this patient needs an admission rather than outpatient/observation care. Let’s hope it isn’t just for nursing home placement as that really isn’t a valid reason for an inpatient admission so it will make your job more difficult.

Assuming there is something that distinguishes these inpatient cases from those who only need outpatient services, then you should review the record for any clinical indicators to support an undocumented diagnosis. Hopefully, your organization allows you to interact with providers so you could approach a helpful individual to gain insight into his/her thought process. Sometimes it is helpful to have a conversation to understand the physician’s perspective. Often providers have great justification for their admissions; they just don’t realize how important it is for their thought process to be documented in the health record.

Just because someone is older and altered does not mean they need inpatient care. First, clarify is the patient usually altered or demented? If the patient has a history of dementia, you need to ask how this encounter is different from the patient’s baseline. Be sure the provider documents in terms of acuity, clarifying this is an “acute” AMS rather than their usual level of impairment. Next, you need to look for clinical indicators to support a diagnosis to clarify the symptom of AMS.  Is it acute confusion? Acute delirium? Metabolic encephalopathy? In coding terms, “altered mental status” has limited “value” when coded so what condition was the provider trying to convey? What was the significance of this finding?

For a patient admitted with a UTI, I might query to ask the provider if the patient is being treated for a local or systemic infection.  If that patient also has AMS, I would query for a diagnosis associated with the symptom of “AMS.” I would also clarify whether there is a cause-effect relationship between the UTI and the diagnosis associated with the AMS. If there is a relationship then you as a CDI specialist would need to clarify the extent of that relationship and how it affects the sequencing of the diagnoses.

You may need to query as to the cause of the admission—the UTI or the AMS (metabolic encephalopathy or acute confusion or acute delirium). If the provider did a CT secondary to AMS, then you would need to ask whether such a scan is typically ordered for a UTI. What was really the concern for the patient?

When thinking about querying, I like to consider the point at which the physician would discharge a given patient. In this situation, would the patient be discharged when the UTI resolves or when his/her metal status clears? If the physician discharges the patient when his/her metal status clears, then the admission is for the AMS (the diagnosis associated with AMS by the provider) as that is the focus of treatment. Just because the diagnosis associated with AMS is associated with a UTI does not mean the UTI is the reason for admission.

Similarly, encephalopathy is always due to something else and just because it is due to a UTI it does not mean the UTI must be assigned as the principal diagnosis. The condition that is being studied is the AMS, which after study, is associated with a diagnosis like acute delirium or metabolic encephalopathy. The reason the person needs admission is because they are altered, not because they have a UTI. Not all patients with a UTI are altered and few patients with a UTI require inpatient care.

Addressing FTT is more difficult. I can’t think of any acceptable alternative principal diagnosis that supports inpatient care. People get old and they become frail, but that doesn’t mean they need inpatient care. In terms of advice, I’d recommend you consider the focus of treatment and work backwards from there. The documentation needs to be clear as to what condition occasioned the admission. You want everyone who reviews the record to come to the same conclusion based on the documentation.

Just because something is “due to” something else does not make the etiology the principal diagnosis, unless the Official Guidelines for Coding and Reporting say the condition is part of an etiology/manifestation pair, such as poisoning and adverse effects.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview. This article originally published on the ACDIS Blog.