Acute cor pulmonale with PE

rvanvught

Hello,

I am hoping to get some opinions. There is a dispute among my coding and CDI staff regarding the sequencing of a patient with both an acute PE and acute cor pulmonale on admission.

There is no coding advice or guideline that anyone found giving direction for sequencing, even though the PE caused the acute cor pulmonale.

There was discussion among my group about what was "treated more", i.e. Lovenox for the PE versus ECHO and monitoring of the acute cor pulmonale. The patient was on oxygen, which of course could be treatment for both. The coding staff is stating that the PE was "treated more" and should be used as principal.

Has anyone run into this clinical scenario before? Any advice?

Thanks,
Robin

Robin Van Vught, RN
Clinical Documentation Specialist
Meriter Hospital
608-417-7593
rvanvught@meriter.com

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kmaritan

Isn't it true that if diagnoses are POA & both being treated, either can
be sequenced principal. If so, I would go for the acute cor pulmonale
because that DRG w/MCC is more reimbursement than PE DRG w/MCC.

evanspx@sutterhealth.org

This is an advanced case, IMO.

Below is a citation endorsed by may explaining the reasoning of "Two or more Dx that equally met the definition for PDX".

Per your description of the Treatment, it 'seems the PE is being treated more intensely than the Acute Cor Pulmonale due to the PE. (PE being treated with Lovenox to resolve the embolism, while the Cor Pulmonale is being treated symptomatically - others may not share my interpretation.



Credit: Faye Brown (AHA publisher).


1. Two or more diagnoses that equally meet the definition for principal diagnosis: In the unusual situation in which two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of the admission and the diagnostic workup and/or therapy provided, either may be sequenced first when neither the Alphabetic Index nor the Tabular List directs otherwise. However, it is not simply the fact that both conditions exist that makes this choice possible. When treatment is totally or primarily directed toward one condition, or when only one condition would have required inpatient care, that condition should be designated as the principal diagnosis. Also, if another coding guideline (general or disease-specific) provides sequencing direction, that guideline must be followed.



Example 1: A patient was admitted with unstable angina and acute congestive heart failure. The unstable angina was treated with nitrates, and intravenous Lasix was given to manage the heart failure. Both diagnoses meet the definition of principal diagnosis equally, and either may be sequenced first.



Example 2: A patient was admitted with acute atrial fibrillation with rapid ventricular response and was also in heart failure with pulmonary edema. The patient was digitalized to reduce the ventricular rate and given intravenous Lasix to reduce the cardiogenic pulmonary edema. Both conditions meet the definition of principal diagnosis equally, and either may be sequenced first.


Paul Evans, RHIA, CCS, CCS-P, CCDS

Unknown

In ICD-10, the issue will be a nonissue as there are combination codes.