Q&A: Identifying the principal diagnosis in liver transplant patient

Q: We recently admitted a 52-year-old man who was waiting for a liver transplant. He has a history of hepatitis C, chronic back pain, and drug and alcohol abuse. He was found unresponsive at home in a pool of vomit. The toxicology screen on admission was positive for benzodiazepine, opiates and amphetamines. 

 

His presenting vitals were temperature of 101.3, heart rate 102, and respirations 28 with blood pressure of 107/65. However, his blood pressure dropped to 74/29 in the ER. The room air saturation was 84% and then he was placed on non-rebreather mask. The chest x-ray demonstrated bilateral lower lobe infiltrates, the ammonia level was 73, he tested positive for a urinary tract infection (UTI), his lactic acid was 3.0 and Bilirubin was 3.0.

 

According to the ER physician the admitting diagnosis was encephalopathy, fever, and overdose. Yet, the history and physical stated hepatic encephalopathy and aspiration pneumonia and the discharge summary stated the primary diagnosis was “unresponsive likely secondary to hepatic encephalopathy with secondary diagnosis of acute hypoxemic respiratory failure and aspiration pneumonia.”

 

The case was final coded to DRG 917, poisoning and toxic effect of drugs with a MCC. My counterpart thought the final DRG assignment  would be 177, aspiration pneumonia with a MCC. I thought it should be 896, alcohol drug abuse or dependence without rehab with a MCC. Infectious disease did not mention SIRS or sepsis in their consult.

 

Can you help us parse this situation out and provide insight into how we should be thinking about cases like this in terms of record review?

 

A: Wow! This one is a challenge. You certainly are not lacking MCCs with this case. I need to break this down a bit to think it through.

 

Based only on what you’ve indicated above let’s assume the patient had the following conditions present on admission:

·         Hepatic encephalopathy

·         Hepatitis C

·         Aspiration pneumonia

·         Acute hypoxic respiratory failure

·         Alcohol abuse

·         UTI

 

So here are few query opportunities you might consider:

 

Sepsis and septic shock based on the clinical indicators. Is the hepatic encephalopathy due to alcoholic cirrhosis or due to the Hepatitis C? Is the Hepatitis C acute or chronic? The patient is waiting for a liver transplant--is this due to acute or chronic liver failure and what is the underlying etiology (alcoholism or Hepatitis C)? If I had the record in front of me I would find even more questions!

 

It sounds as though the coding staff coded this to a poisoning likely due to the Official Guidelines for Coding and Reporting. There are several sequencing guidelines that come into play when coding a poisoning or reaction to the improper use of a medication (e.g., wrong dose, wrong substance, wrong route of administration). In these instances the poisoning code is sequenced first, followed by a code for the manifestation. If there is also a diagnosis of drug abuse or dependence to the substance, the abuse or dependence is coded as an additional code. I do not have the record in front of me but if it is not completely clear that this is a poisoning (wrong dose, wrong substance, wrong route, etc.) you would need to query to clarify.

 

My guess is this was an overdose, and if so, another question would be was this intentional or accidental? These answers are most likely very clear within your record.

 

Lastly, just because the toxicology screen is positive for those substances, it does not mean that they were responsible for the patient’s presenting symptoms. I emphasize this because this is a key question and the wording of the discharge summary seems to answer this.

 

The physician stated, “unresponsive likely secondary to hepatic encephalopathy with secondary diagnosis of acute hypoxemic respiratory failure and aspiration pneumonia.” This wording tells me the primary concern for this patient and the contributing factor to his unresponsive state was the hepatic encephalopathy. Due to this wording, I would take the hepatic encephalopathy as the principal diagnosis. This would lead to the DRG 441, disorders of the liver with MCC.

 

However, if you do get a confirmation of the presence of sepsis on admission this would be your principal diagnosis.

 

These cases can be such a challenge. And this is where the concurrent review can be so helpful. An effective route might be to try to speak one-on-one with the physician to discuss the issues of the positive toxicology screen and possible poisoning, and also to determine the underlying etiology of the cirrhosis. For example, what process is likely responsible for the patient’s presenting symptoms?

This is also a great opportunity for physician education about the importance of wording and how this will affect the principal diagnosis selection. As I said, when the case presents with so many unknowns and so many questions, it is often best to speak one-on-one with the physician. Once you understand the physician’s determination of underlying cause, you can assist with clarifying to obtain supporting documentation. Hopefully, when these discussions occur concurrently, by the time the account hits the coder the documentation will be clear and no further questions would be needed.

 

The Official Guidelines for Coding and Reporting pertaining to poisoning can be frustrating and confusing. I would suggest you review those as they pertain to this case and review the actual wording within the record. Also discuss this situation with the coding staff to understand their choice of this principal diagnosis. Discussions and review of the guidelines as they specifically pertain to such a case can be a learning opportunity for all.  

 

Editor’s Note: Laurie L. Prescott, MSN, RN, CCDS, CDIP, is a CDI Education Specialist with HCPro Inc., in Danvers, Mass., and a lead instructor for its CDI-related Boot Camps. For more information regarding upcoming Boot Camp dates and locations visit www.hcprobootcamps.com/courses/10040/location-dates.