987 non-extensive O.R. procedure unrelated to principal diagnosis w MCC

catherine.bumgarner

Hello,

I am in need of help to try and get out of this DRG. Pt comes in complaining of RUQ abdominal pain and right knee pain. Principal diagnosis is coded as 996.62-infection and inflammation reaction due to other vascular device, implant, or graft. She has an immature AV fistula and a permcath used for dialysis. Blood cultures positive for MRSA and the permcath was removed, the tip was cultured and also found to be MRSA positive. Additional permcath was placed for dialysis. Patient is also septic, POA. She goes into cardiac arrest due to high potassium, intubated and placed on a vent. While on the vent, she undergoes and I and D with knee synovectomy, knee arthroscopy, partial lateral meniscectomy and multiple areas of condroplasty due to preoperative diagnosis of right knee pyarthrosis. Post op diagnosis are right knee pyarthrosis, synovitis, chondromalacia, and lateral meniscus tear. Knee fluid grew MRSA.

Upon verbal query with the neprhologist, he is unable to determine if the IJ permcath or the knee is the primary site of infection.

The attending dictates the following: MRSA bacteremia, sepsis and septic shock with positive blood culture from the right IJ perm-cath and secondary seeding of the right knee causing septic joint.

The coders insist we are in the correct DRG. Your opinions? Any suggestions on how to move the DRG?

Thanks!

Catherine Bumgarner, RN, BSN, MSN
CDIS at Memorial Hospital of Martinsville
320 Hospital Dr
Martinsville, Va 24112
770-760-7179
catherine.bumgarner@lifepoint.net

evanspx@sutterhealth.org

I have no coding references (Traveling) as I respond; but, the DRG assigned by the coders is correct because:

The patient was admitted with sepsis and an O.R. Procedure 'unrelated' to the sepsis was performed.

This yields DRG 987, per your message ( I can't group the case).

For whatever reasons, some have been told this DRG should be avoided - however, there is no reason not to assign this DRG when compliant.

I have no Encoder or references as I am traveling, but this question is fielded many times and probably because of the title of the DRG.

As the patient was admitted with sepsis, apparently due to 996.62, AND a valid O.R. procedure upon the knee was performed due to seeding, the DRG was generated.

Per your description, there is no other principle diagnosis to consider - a different code used as the principal could change the DRG, but it does not seem an alternative exists due to the Guidelines for principal diagnosis selection and Sepsis.

Best,

Paul Evans,

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002
Fax:  415.600.1325
Ofc:  415.600.3739
evanspx@sutterhealth.org

ddouthit

Catherine,

Based on the attending documentation is sounds like your Sepsis and septic joint are both secondary to your perm-cath. This results in 996.62. With the procedures you have this groups to a 987 and you are stuck with that DRG.


Sepsis due to vascular catheter
      Coding Clinic, Second Quarter 2004 Page: 16 Effective with discharges: August 10,2004

Clarifications

Sepsis Due to Vascular Catheter

Question:

Coding Clinic, Second Quarter 1994, page 13, advised to assign code 996.62, Infection and inflammatory reaction due to other vascular device, implant, and graft, for septicemia due to a vascular access device. Does this advice still apply when a patient is admitted with sepsis due to vascular catheter? Is the principal diagnosis sepsis or infection of vascular catheter?

Answer:

Note from 3M:
As of October 1, 2011, new codes have been created to distinguish between local (999.32) and systemic (999.33) infections due to central venous catheter. Also, code 999.34 was created to classify an acute infection following a transfusion, infusion or injection of blood and blood products.

Note from 3M:
As of October 1, 2006, further revisions have been made to subcategory 995.9. See Coding Clinic, Fourth Quarter 2006, pages 113-116.

When a patient has sepsis due to the vascular catheter, code 996.62, Infection and inflammatory reaction due to other vascular catheter, should be the principal diagnosis, followed by the appropriate sepsis code, generally a code from category 038 and a code from subcategory 995.9. If no organ dysfunction is involved, then code 995.91, Systemic inflammatory response syndrome due to infectious process without organ dysfunction, should be assigned following the sepsis code. If the infection has advanced to severe sepsis, SIRS with organ dysfunction, then code 995.92, Systemic inflammatory response syndrome due to infectious process with organ dysfunction, should be assigned with additional codes identifying the specific types of organ dysfunction.

If the term septicemia is used to describe the infection, the physician should be queried as to whether the patient has sepsis. If the infection is documented as septicemia due to a vascular catheter, then code 996.62 should be the principal diagnosis followed by code 038.9. No code from subcategory 995.9 should be assigned with a diagnosis of septicemia. If SIRS is documented, then the patient, in fact, has sepsis, and a code from subcategory 995.9 should be assigned.


Dorie Douthit, RHIT,CCS
CDI Program/HIM
706-389-3364
St. Mary's Health Care System
1230 Baxter Street
Athens, Georgia 30606

sharon.cole

Based on what is presented, 996.62 is the correct principal dx. I would have assigned to the same DRG.

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

evanspx@sutterhealth.org

Thanks, Dorie, for the citation.

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002
Fax:  415.600.1325
Ofc:  415.600.3739
evanspx@sutterhealth.org

catherine.bumgarner

Thank you all so much for your validation. I am new to my position and thought that since the knee and the perm cath both grew MRSA that they would be related to the prinicipal diagnosis. Since the actual knee surgery was not related to the infection, can I assume that the MRAS in the knee was just a coincidence?

Catherine Bumgarner

ssalinas

I am a coder, not a clinician, and am asking for a little education here.

Is an IJ permacath used for dialysis centrally placed or peripherally placed? The scenario below referenced an IJ permcath which I have considered a centrally inserted line. Is this incorrect? If it is incorrect, I agree with the assignment of 996.62 as prin dx. If it is considered central venous cath, then I think 999.32 should be used as prin dx. The resulting DRG is still the same (987).

I have pasted a CC that addresses the 996.62 vs. 999.32 issue. I just need to know if an IJ permacath is considered peripherally or centrally inserted.

Thank you in advance -


Infection due to dialysis catheter
Coding Clinic, Second Quarter 2010 Page: 8 Effective with discharges: July 7, 2010

Question:

What is the code assignment for infection due to dialysis catheter?

Answer:

The answer would depend on the location of the catheter, since additional information is needed to determine the correct code assignment. For example, if the infection is due to a centrally placed catheter, assign code 999.31, Infection due to central venous catheter. If the infection is due to a peripherally placed catheter, assign code 996.62, Infection and inflammatory reaction, Due to vascular device, implant and graft.