Tip: Take care sequencing diagnoses

For example, a patient presents with congestive heart failure (CHF) and pneumonia, both of which are treated and both of which support the medical necessity of the admission. Coders may sequence either diagnosis as principal, according to the Official Guidelines of Coding and Reporting.

 

When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, the official coding guidelines allow coders to report either diagnosis as principal, provided the Alphabetic Index, Tabular List, or another coding guideline do not provide sequencing direction.

 

As the above example is currently documented only pneumonia is an MCC. If coders sequence the CHF as principal, the case will map to a higher-weighted MS-DRG because of the secondary MCC of pneumonia, says Ericson. If coders sequence the pneumonia as principal, then a query to the physician would be needed to obtain the specificity and acuity of the CHF to capture an MCC. CHF, unspecified is neither a CC nor an MCC.

 

“Therefore, using the CHF as the principal diagnosis and pneumonia as the MCC requires less work because querying is not required to finalize the DRG assignment,” says Ericson. Develop policies, procedures, and criteria for how to handle these types of scenarios although they shouldn’t occur too often, she says.

 

“I think it’s helpful to provide coders and CDI specialists with training on utilization review,” says Ericson. “Coders need to be aware that the principal diagnosis must be supported by medical necessity. A patient can’t be admitted to an inpatient setting without medical necessity. Not all diagnoses will support an inpatient admission.”

 

Editor’s Note: This article was originally published on JustCoding.com. Join William E. Haik, MD, FCCP, CDIP, Wednesday, January 9, at 1 p.m. (EST), for the audio conference “FY 2013 CC/MCC List: Clinical Indicators and Query Opportunities,” as he explains the guidelines for reporting additional diagnoses and explores the significance of the latest CC/MCC changes including definitions for malnutrition and acute kidney injury (AKI). During the audio, Haik will offer helpful tips to incorporate significant documentation elements to reflect the patient’s condition.

 

Visit the ACDIS website, Helpful Resources page, to download fiscal year 2013’s CC/MCC list and while there download the ICD-10 version to review. Scroll down to “Coding Resources” and view the last four bullets.