Q&A: Fluid overload in ESRD patient

Q: I need help identifying the principal diagnosis for the following situation. The patient presented with shortness of breath and hypoxia, and had emergent dialysis which resolved his symptoms. However the patient’s international normalized ratio (INR) was sub therapeutic due to his end stage renal disease. A high dose of warfarin had to be given, and the patient was admitted as inpatient. I am trying to decide if this would be a principle diagnosis of fluid overload (276.69) or abnormal coagulation profile (790.92)

A: The patient had fluid overload, was emergently dialyzed, and “symptoms resolved post dialysis” which suggested to me that the fluid overload was resolved, and they were prepared to discharge the patient. However, the INR was noted to be too low, and it was not possible to bridge with Lovenox injections on an outpatient basis, so needed to be admitted to manage the anti-coagulation (get the INR to goal levels).  So, the reason for the patient becoming an inpatient was the INR, not the fluid overload that was resolved prior to the decision to admit, so I would go with 790.92.

Editor’s Note: This question was answered by ACDIS Advisory Board member (at the time of this article's original release) Donald A. Butler, RN, BSN, CDI Manager at Vidant Medical Center in Greenville, North Carolina.