Coding Question/DRG Validation

arsusott@msn.comarsusott@msn.com
in CDI Talk Archive
I have a patient that was admitted for an exacerbation of interstitial lung disease. The H&P states CHF that is stable. The progress notes the next 2 days state CHF acute on chronic diastolic. (I don't have the chart in front of me at this time so I am not sure if meds were changed, etc.) The d/c summary states stable chronic diastolic CHF. This chart was coded with the ILD as pdx and then the acute on chronic diastolic chf as the mcc. Is the D/C Summary always the final rule? There is a 2000 2nd Q Coding Clinic about about clear vs inconsistent documentation. However; my thoughts were that the doctor without querying stated acute on chronic in the progress notes so I felt it was "codeable". Any thoughts on this? I always thought the d/c summary was used as a helpful tool as to what happened during the patients stay but not the rule.


Thank you for your help.

Comments

  • Unknown
    edited May 2016
    I preach to my team, "When in doubt, clarify!" To get a definitive answer that will appease the coders and auditors you should probably ask for an addendum clarifying whether they stabilized during this admit or if they presented to the ED with stable chronic CHF.

    --Juan


  • nbrunson84nbrunson84
    edited May 2016
    Are you wanting the CHF as your PDx? You will take a "hit" in your DRG
    if you do that.

    My first inclination is to check and make sure the patient met the
    indicators for Acute - was BNP Elevated? Any indication on the CXR?
    Was IV Lasix given? Or PO adjusted? ECHO?

    There is a rule for Coding when a patient is admitted with two
    co-existing diagnoses on admission - both treated equally throughout the
    stay - or on admission - that the coder has the choice to pick the
    higher weighted DRG - in that case the ILD w/an MCC (Ac on Chr DHF).

    The DC Summary is usually the "last word" of a physician. However, if
    the Dx is not mentioned in the DC summary it doesn't mean it wasn't
    treated. You may have to have him address the diagnosis in an
    "addendum" to his DC Summary - Pre-RAC days.



    N. Brunson, RHIA
    Clinical Documentation Specialist
    Bay Medical Center


  • mannb1mannb1
    edited May 2016
    Question: were there different providers following the patient which would explain one saying acute on chronic, and the d/s saying chronic HF (happens in our facility a lot!)? I would use the acute on chronic as an MCC, but likely discuss w/the coders if there was a need for clarification/query.


  • arsusott@msn.comarsusott@msn.com
    Thank you for your comments so far. The pdx is definately ILD but the question was for the MCC of acute on chronic diastolic CHF. The BNP did jump during the admission, patient was treated with IV Furosemide. This chart was coded as ILD as pdx and acute on chronic diastolic CHF as the mcc. We received a DRG change notification from VARIS, LLC that said that this should have been coded as chronic diastolic chf. However; I disagree thinking that on d/c it was stable but during admission it was acute.

    Thanks again for any guidance you can give me.
  • nbrunson84nbrunson84
    edited May 2016
    I was checking out some POA info. The coder will probably have to Code
    the 428.33 code as "N" but the 428.0 as "Y".


    N. Brunson, RHIA
    Clinical Documentation Specialist
    Bay Medical Center


  • Unknown
    edited May 2016
    It appears this is >30 post D/C. In addition, this has already been billed. Consequently, your best approach will be to work with whatever dept handles your hospital's insurance contract appeals. They'll draft an appeal letter if they deem it appropriate. Otherwise, all you can do is use this for future reference.

    --Juan


  • Unknown
    edited May 2016
    I thought the same thing as you. Most of the time our coders seem to use
    it as the final rule.

    Gina Spatafore, RN
    Clinical Documentation Integrity Specialist
    Waterbury Hospital
    203 573 7647


  • dogdog
    Our coders take the d/c summary as final, but if there is a significant discrepancy between it and the progress notes, particularly a progress note written near the time of discharge, they will usually ask me to get the discrepancy clarified before they finalize the chart. Your scenario, to me, would have qualified as a significant discrepancy.

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Arizona Heart Hospital
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