Metabolic Encephalopathy as PDX
Good Morning
When I was trained as a CDI we were told Metabolic encephalopathy would rarely be the principle diagnosis as there is always something that causes it.
So, here is my question. Our coder coded Metabolic encephalopathy as the PDX and I would like some input from our great community if that is really the most appropriate PDX in this case. I thought the renal failure would be more appropriate?
Patient is admitted to hospital with acute renal failure and AMS documented on H&P. 2 days later physician documents ‘AMS, probably delirium from underlying metabolic and infectious problems.†He also started documenting metabolic encephalopathy around this time. Neurologist is consulted and CT head, MRI and EEG are ordered to r/o CVA and seizure. Physician documents “seizures could not be excluded†and pt is started empirically on Keppra. Initially IV then p.o. (with which she is also dc’d). Nephrologist is consulted for abnormal renal function and very heavy proteinuria, reason for proteinuria remains unclear and will be followed OP. Acute renal failure is treated with fluids and renal panel is drawn daily for length of admission. Nephrologist documents improvement of acute renal failure daily and continues to see her till dc. By day 4 the AMS and renal failure is both documented, by primary, as resolved and on day 5 physician documents pt back to baseline with regards to her AMS. Also, during the rest of the stay, patients is treated for a UTI (not POA) and infected chest wound dehiscence (POA) tx IV abx. Pt was in hospital for 8 days.
Thank you in advance for your input.
Renee Meyer, RN
CDS
Rideout Health
When I was trained as a CDI we were told Metabolic encephalopathy would rarely be the principle diagnosis as there is always something that causes it.
So, here is my question. Our coder coded Metabolic encephalopathy as the PDX and I would like some input from our great community if that is really the most appropriate PDX in this case. I thought the renal failure would be more appropriate?
Patient is admitted to hospital with acute renal failure and AMS documented on H&P. 2 days later physician documents ‘AMS, probably delirium from underlying metabolic and infectious problems.†He also started documenting metabolic encephalopathy around this time. Neurologist is consulted and CT head, MRI and EEG are ordered to r/o CVA and seizure. Physician documents “seizures could not be excluded†and pt is started empirically on Keppra. Initially IV then p.o. (with which she is also dc’d). Nephrologist is consulted for abnormal renal function and very heavy proteinuria, reason for proteinuria remains unclear and will be followed OP. Acute renal failure is treated with fluids and renal panel is drawn daily for length of admission. Nephrologist documents improvement of acute renal failure daily and continues to see her till dc. By day 4 the AMS and renal failure is both documented, by primary, as resolved and on day 5 physician documents pt back to baseline with regards to her AMS. Also, during the rest of the stay, patients is treated for a UTI (not POA) and infected chest wound dehiscence (POA) tx IV abx. Pt was in hospital for 8 days.
Thank you in advance for your input.
Renee Meyer, RN
CDS
Rideout Health
Comments
AHA Coding Clinic® for ICD-9-CM, 1Q 1988, Volume 5, Number 1, Pages 3-4
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
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
Following the above recommendations of Paul, I have participated in a
successful appeal to a RAC denial for a case with encephalopathy coded as
PDX. The RAC wanted to resequence encephalopathy as an MCC vs the PDX
resulting in a lower reimbursement figure, but thanks to concurrent review
and physician documentation supporting the diagnosis & treatment, it
withstood scrutiny. I wish I could remember the case details to share.
Question - was any of the care directed toward the chest wound
infection/dehiscence? Utilizing this post-op complication (if that's what
it was) carries the highest RW and has a much better DRG/LOS match. Based
on the details you provided, treatment seems equally driven toward both the
encephalopathy and ARF. Certainly, the ARF as PDX is a much better DRG/LOS
match than encephalopathy as PDX. I'm wondering how open your coder is to
discussion re: eligibility for both as PDX - and then choosing the highest
RW? It seems like a reasonable discussion based on the details provided.
Cindy Prithcett, RN, BSN, CCDS
MedPartners CDI Consultant
I was wondering, with the provided info, if there is a reason why the renal failure could not be the PDX. From Cindy's answer it seems that is certainly a possibility. Cindy I did discuss it with our coder but she felt the treatment was focused on the AMS. This was the reply from the coder. "All focus (eight day stay) was on this encephalopathy. I know the renal failure pays more, but, when this chart is reviewed by RAC, I guarantee that they will make us change that diagnosis to encephalopathy, because it is the focus of treatment.". I don't think the focus was only on the encephalopathy and think we sometimes get caught up in choosing the lowest RW so that we can't be accused of being 'out for the money"
I presume the post op complication can't be the PDX because it was treated with IV abx on a OP basis prior to this admission. (please correct me if I'm wrong).
Thanks for the input.
Renee
healthy conversations re: each other's positions. If that is not possible
at this point, having a process in place to avoid creating a rift between
the disciplines, a second level review would be recommended. Does your
organization have this process? Usually, discrepancies between CDI and
Coding are referred "up the chain" to the facility's designated subject
matter expert (usually a lead coder or corporate resource) for the final
determination.
I have worked in systems that are in the early phases of implementing CDI
and resistance between the groups can be quite unpleasant. If you have a
good working relationship with your coding group, perhaps discussing the
coding clinic defining PDX and asking the coder to help you understand why
the ARF is NOT an eligible pdx based on existing documentation and
treatment might be a great starting place. If you don't, my belief is that
there should be a 2nd-level review process in place to remove the
"battling" that can go on if not careful. The process helps remove any
attached emotions and usually results in a learning opportunity for one or
both involved.
Cindy Pritchett, RN, BSN, CCDS
MedPartners CDI Consultant
Cindy.pritchett04@gmail.com
On Fri, Nov 1, 2013 at 1:01 PM, CDI Talk wrote:
> Thanks for the replies. I realize that the encephalopathy could be the
> PDX. In this specific case it would have the lowest relative weight and if
> both conditions are treated equally
RE: PDX - as you stated so well, if the documented circumstances of admission, w/u and therapy allow, one may sometimes have sequencing choices. Coding Clinic and coding references must also be vetted.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
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
We are usually taught to look for an underlying cause of encephalopathy because it it is usually a manifestation of something else.
There is a coding rule which addresses the possibility of more than one diagnosis being the source of encephalopathy. If its not clear which diagnosis is the culprit, the "symptom" has to be coded as PDx listing the possible causes as SDx.
Norma T. Brunson, RHIA, CDIP,CCS,CCDS
and CDI is an essential factor for success.
I had a blog post on the topic (from way back in Aug 2010); even though
old I don't think it's outdated.
ACDIS poll illustrates need for DRG reconciliation process
http://blogs.hcpro.com/acdis/2010/08/acdis-poll-illustrates-need-for-drg-reconciliation-process/
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation Advisor Program
Vidant Health, Greenville NC
DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )
Renee