Coding question for the use of tPA

kristen.anderson

I need some help with a conflict of opinion that we are having regarding the coding of tPA. We had a patient who was admitted w/ a CVA as well as a malignant pleural effusion for which a pleural drain was placed. The patient was not a candidate for the use of thrombolytics to treat the stroke, however, days into the admission Alteplase was used to aid in facilitation of drainage of the loculated effusion. This was coded to DRG 61 CVA w/ the use of thrombolytic agent. As CDS we felt it was clear that the thrombolytic agent was used as a medication, not as treatment of the stroke therefore, it should not be coded as such, as this would affect statistics and reporting for our stroke center. The argument the coder had was that she was trying to capture the use of tPA and that this was an expensive treatement and there was no other ICD-9 code to use.

We explained that the thrombolytic was being used for a completely different purpose and it would be charged appropriately as a medication. We are now being asked to work with the coder to draft a question to send to coding clinics. We feel this is ridiculous and quite frankly don't want to be any part of asking such a question. I was just hoping to get some input that will either confirm my feelings or give me another perspective.

Thanks!

robert.hodges2

I agree with you. The treatment used is not the code assigned. ICD-9 Procedure Code 39.50 "Thrombolytic agent - specified site NEC" is a possibility and will capture the infusion. The coding must be supported by the documentation and this certainly doesn't seem to be the case. I sure wouldn't want to be the coder if this was audited.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
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E: Robert.Hodges2@va.gov
 
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

vivian.gannon

Yikes! I agree with you 100%. There shouldn't be any question, as it appears from your notes here the documentation is quite clear.

Vivian

mdominesey

This is exactly why we CDSs have a seat at the table! I almost think that this could go either way if audited - a honest mistake on the coder's part (now unlikely considering your education and intervention), or clear a False Claims Act violation (see, I did learn something from the conference!)(not all cd & record shops and walking along the sea cliffs)

I would not want to be the one responsible for a False Claims award against my hospital! Your advice to the coder is spot-on!

Mark


Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital

Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695

W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org

http://www.sibley.org

sharon.cole

It's obvious from the information provided that the tPA was not used to treat the CVA. Would that not be considered fraudulent to code something when the documentation clearly does not support it? When you know the drug was not used for the purpose indicated by the DRG?

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

kari.eskens

I just have to throw a different opinion out there. Please help me understand what I am missing in this scenario. I do not think the coding of this drug is as clear cut as everyone seems.

The description of code 99.10 is Injection or infusion of thrombolytic agent. This includes the use of alteplase. It does not indicate the intent or use for this drug, only that it was given. It is the coders role to accurately code all diagnosis and procedures that were done during the course of admission. It seems to me coding this administration is not wrong. The drug was given, and it is a thrombolytic.

Where the dilemma lies is in the DRG assignment when this code is present. That isn't anything the coder can control. The presence of these to codes will take it to DRG 061. Wouldn't the fact that the CVA was present on admission and the administration of the drug was done several days later paint the picture that it was not given to treat the CVA? If DRG 061 did not come into play, would you think it was still inaccurate to code 99.10 in this situation?

Kari L. Eskens, RHIA
BryanLGH Medical Center
Coding & Clinical Documentation Manager

ddouthit

I completely agree with Kari...however to throw another wrench in the scenario. Is it possible that the focus of the treatment was on the malignant pleural effusion and therefore this meets definition of principal diagnosis over CVA? DRG 180 weight is much, much less than DRG 061...so would have to weigh guidelines of two or more conditions both equally treated also.
Dorie Douthit, RHIT,CCS
CDI Program/HIM

Unknown

Wouldn’t the pleural effusion be the principle diagnosis. Focus of care due to pleural drain and thrombolytic agent. CVA would be secondary

Tracey Carey RN
Clinical Documentation Specialist
UAMS
686-7421

kristen.anderson

Just to clarify this case, the patient had progressive stage IV adenocarcinoma of the lung with extensive pleural and bony metastasis. She was s/p 2 courses of chemotherapy and was due for her third course of chemotherapy. She was admitted w/ a CVA. The pleural effusion was not a new diagnosis. It was an ongoing issue for this patient given her extensive cancer. The pleural drain placement was a palliative measure.

dvitalone1

We have a policy in place that states when there is a DRG mismatch /conflict of DRGs or PDx between CDI and Coding staff we send it to the coding supervisor.

sharon.cole

After reviewing this with my new CDIS Coder (yay, we've been a long time waiting for her to come along!!), she felt that the record was coded to the correct DRG. The coder cannot help that the codes map out to a specific DRG. This happens in other DRGs where the correct code takes you to something that seems odd. I retract my previous statement.

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

cindy.edmonds

Also, remember the actual bill drop will have the date the drug was administered, thus showing not for current CVA. Thanks for the good discussion folks!

ssalinas

Coders do not have the privilege to personally decide which diagnoses/procedures to code. We are required to follow CMS rules for IPPS coding and the UHDDS Guidelines for the reporting of procedure codes which state that all procedures affecting determination of payment or procedures that carry significant risk or require specialized training must be reported. 99.10 is used for injection or infusion of thrombolytic agent which is given hypodermically or intravenously and acting locally or systemically. Does this describe what was done? If so, it must be coded to be in compliance with CMS and USDDS Guidelines.

Sometimes a procedure will increase reimbursement but there are also times when it decreases payment. Regardless, if the procedure meets reporting guidelines, it must be reported. An example of reducing reimbursement is a patient with DRG 207 who has a debridement, This will reduce payment by varying amounts depending on the depth of debridement.

Just read your last email Sharon and thank you for coming to defense of coders. At times coders are just as dismayed by the DRG assigned as you are. We do not code to achieve a desired DRG. We assign codes accurately and completely following established guidelines and rules. The resulting DRG is the result of the IPPS MS-DRG system.


Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336

kristen.anderson

"99.10 is used for injection or infusion of thrombolytic agent which is given hypodermically or intravenously and acting locally or systemically"

This does not describe how the tPA was used in this case. It was not injected or infused hypodermically or intravenously. It was put into the pleural drain tubing to facilitate drainage. The use of the tPA in this case is similar to how it is used when a PICC line gets clogged.

ssalinas

Thanks for clarifying how it was used. I wasn't sure so that is why I asked the question in my earlier email. However if it is similar to how it is used when used to declog a PICC line, then 99.10 is still probably correct based on the Coding Clinic below. (The clarification note deals with the diagnosis code given, not the procedure code.)

Clotted peripherally inserted central catheter
      Coding Clinic, Second Quarter 2011 Pages: 4-5 Effective with discharges: June 24, 2011

Question:

A five-year-old child was admitted for chemotherapy. It was discovered that he had a clotted peripherally inserted central catheter (PICC) line. He required central access to complete his chemotherapy for acute lymphocytic leukemia (ALL). The line was declotted using Alteplase, which was instilled into the catheter. This dissolved the blockage and the line could be used again. How should this case be coded?

Answer:

Correction/Clarification Notice:
Correction published in Coding Clinic, 1st Quarter 2012, page 18.

Assign code V58.11, Encounter for antineoplastic chemotherapy, as the principal diagnosis. Assign codes 204.00, Lymphoid leukemia, Acute, Without mention of remission, for the ALL and 996.1, Mechanical complication of other vascular device, implant, and graft, for the clotted PICC line as additional diagnoses. Assign code 99.25, Injection or infusion of cancer chemotherapeutic substance, and code 99.10, Injection or infusion of thrombolytic agent, for the procedures.


Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336

mdominesey

From what I can see, because the person was admitted with the CVA, that was the reason they came in on that particular day. They may or may not have come in later for treatment of the pleural effusion.

Going to an acute care hospital after/during a CVA would be appropriate even if someone was on hospice or palliative care with a total DNR status in order to get assessed to reduce the chance of something very painful happening - i.e. aspiration and death due to sudden asphyxiation (chronic reduced O2 kills differently an arguably with less pain and sudden anxiety at the time of death)

Kindest Regards,

Mark



Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital

Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695

W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org

http://www.sibley.org