Linking s/s with underlying conditions

sharon.colesharon.cole
edited May 2016 in CDI Talk Archive
Hello group, I could really use some help!
We are having a dispute with a group of physicians over documentation to link s/s to underlying conditions and they want something in writing to support the verbiage coding is requesting.
Documentation:
H&P: CP in a patient with known CAD.
CDIS placed query for etiology of CP and got no response in the progress notes.
DC Summary: CP in a patient with known CAD.

This was coded with a PDX of chest pain and the physicians feel it should be coded as CAD. On one hand I can see their point but on the other, I don't know that we can assume the CP is due to the CAD just because the patient has a history. There are people with CAD who come in with CP which, after study is determined to be due to GERD, musculoskeletal pain, anxiety, etc.

Is there anything documented in the literature that says HOW or WHAT VERBIAGE should be used to connect the CP and CAD? Our coding staff says the preferred verbiage should say "due to". I have suggested that as well as "related to", "caused by". But I STILL need it in writing per Medical Director's request.

Thanks in advance
Sharon


Comments

  • vdavis2vdavis2
    edited May 2016
    MD's forget Medicine is not an exact Science. They can use "Possible, probably, likely, suspected" if they don't want to be "locked in." Better if they would say "CP likely caused by known CAD." Sounds like the MD group just wanted to be vague just in case the CP wasn't really caused by the pt's CAD. The MD's document and use symptoms every day. They don't have to deal with "Symptoms Codes" so they don't understand the rationale behind the query. I would quote the MD's the message that pops up in 3M when you try to use a symptom code for Pdx: "This condition should not be used as Principal Diagnosis when a related definitive condition is present." I think "Due to" or "related to" or "Caused By" all mean the same thing.

    One of our MD's frequently used "Atypical CP, plan-medical management." Finally one day I asked him- "Atypical for what?" -A woman, a diabetic, an MI?? And what are you medically managing? Finally-the light bulb went off… He said "Atypical for an MI and the patient has CAD that couldn't be corrected with an intervention so it is being treated medically." He figured out he should have used "Angina with CAD." ☺

    Good luck! ☺



    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens


  • catladyrncatladyrn
    "XXX is a symptom that, when used as a diagnosis, may inaccurately reflect the true severity of illness or resources used in the care of your patient. In order to bring clarity and precision to the medical record and capture the appropriate severity of illness, would you please clarify which, if any, of the following diagnoses, either confirmed or suspected, best describe the condition you are managing."

    Renee

    Linda Renee Brown, RN, CCRN, CCDS, MA
  • robert.hodges2robert.hodges2
    edited May 2016
    Exactly what you said Renee. That's one reason we have "signs and symptom" query forms for abdominal pain, chest pain, respiratory symptoms, neurological symptoms, and just general signs and symptoms. It's far too common a request and always needs clarification.

    Robert
     
    VA Core Values:  Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
    VA Core Characteristics:  Trustworthy, Accessible, Quality, Innovative, Agile, Integrated

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
     
  • sharon.colesharon.cole
    edited May 2016
    OK, don't think I was very clear. The physicians felt their documentation was good enough "CP in a patient with known CAD" to code the CAD as principal. Coding feels is must more clearly link the two by saying due to, related to, caused by, etc. The physicians now are demanding something in writing (such as a coding clinic or guideline) that tells them the coding staff are correct. All I have been able to find is: CC 4thQ, 1093, #4, pages 43-44.

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org


  • vdavis2vdavis2
    edited May 2016
    Coding Guideline Under B. General Coding Guidelines #6- Signs and Symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purpose when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 16 of ICD-9-CM, symptoms, signs, and ill-defined conditions (codes 780.0-799.9) contain many, but not all codes for symptoms."

    However, I think your MD's are referencing this Coding Guideline:

    Section I: Conventions, general coding guidelines and chapter specific guidelines
    A. Conventions for the ICD-9-CM,
    #8. "With"
    "The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the alphabetic index or an instructional note in the Tabular List. The word "with" in the alphabetic index is sequences immediately following the main term, not in the alphabetical order."

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens


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