Principal diagnosis on acute-acute transfers?

dogdog
in CDI Talk Archive
I have been tasked with drafting an appeal regarding a denial letter for wrong principal diagnosis. The patient was admitted to the outside hospital with a respiratory diagnosis, but was transferred here because of an arrhythmia that later developed. Both the respiratory diagnosis and the arrhythmia were treated here. We chose the respiratory diagnosis. The payor disagrees, and states that we should have chosen the arrhythmia as it was the reason for transfer.

I have been searching exhaustively but have been unable to find any reference that would clarify this one way or the other. "Patient transferred with unresolved myocardial infarction, Coding Clinic, Fifth Issue 1993" is the closest I can come to being on point. Would appreciate any and all help in resolving one way or the other. Thx,

Renee

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

Comments

  • digardskdigardsk
    edited May 2016
    We receive a number of transfers from a sister hospital. In selecting the Pdx, we look at the reason for the transfer - the condition that couldn't be treated where they were. Also, where were the most resources targeted? In general, I would think that the arrhythmia would bet the Pdx in your scenario.

    I would think that the premise "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care" would fit here. They were already able to be treated for the resp condition in the outside hospital.

    My thoughts!

    Kim



  • bea.smithbea.smith
    edited May 2016
    I agree with Kim. The respiratory condition was already being treated,
    but they had to transfer to you for the arrhythmia- that is the reason
    for admission at your facility. Sometimes it's the lower paying DRG, and
    I hate it when that happens.


  • sharon.cooper@owensborohealth.orgsharon.cooper@owensborohealth.org
    Each case has to be evaluated on an individual basis.

    As there is no coding clinic I am aware of that addresses the issue.

    My contention would be that if there are multiple causes still being managed and treated upon transfer, then I would be able to apply the coding guideline of two conditions present and treated on admission.
  • jolene.filejolene.file
    Hi Renee!
    I agree with Kim.
  • dogdog
    Thanks to everyone for the answers. We have decided not to pursue the appeal.

    I do have a hypothetical followup question, though: suppose the reason the sending hospital transferred the patient turned out to be bogus? Say that the EP doc evaluated the patient and decided there was no arrhythmia. What would be our pdx then?

    [When I was still an ICU nurse, I had a pt who was transferred to us for "ventricular fibrillation." He had complained of abdominal pain, but they never worked it up, but saw this "VF" on a rhythm strip and whisked him down to us. Turns out the "VF" was complete artifact that even our first year nursing students recognized, and we found there was nothing more wrong with him than a bad case of constipation. Clearly they could have given him a laxative at the outside hospital, which is all we did for him. What would our pdx be?]

    Renee
  • digardskdigardsk
    edited May 2016
    I think it would be the constipation! Came from the presumed arrhythmia, after study found the VF to not be an issue, and the treatment focused upon the abd pain - constipation.

    Kim


  • robert.hodges2robert.hodges2
    edited May 2016
    That almost sounds like an EMTALA violation. I would have your medical staff contact that hospital and complain and potentially file a complaint with the state if it continues.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "Anyone who has never made a mistake has never tried anything new." -Albert Einstein 


  • jolene.filejolene.file
    Good Morning, Renee!
    I would agree that the "constipation" would be the principal diagnosis.
  • susankleinsusanklein
    edited May 2016
    Constipation is usually not a diagnosis used for justifying an acute
    admissions - I would question fecal impaction instead which profiles to
    bowel obstruction.



    Susan A. Klein, BSN, RN, C-CDI

    Saint Peter's University Hospital

    Director, Clinical Documentation Mgt

    office: 732-339-7613

    fax: 732-745-5944 (specify room B175)

    pager: 732-651-4359


  • digardskdigardsk
    edited May 2016
    That is a UR issue. However clearly worthwhile to explore if there was
    a fecal impaction or not.


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