Complex case

jlightfoot@marshallmedical.orgjlightfoot@marshallmedical.org
in CDI Talk Archive
We have a complex case with multiple Pdx choices. The short story is that our coder has chosen pulmonary fibrosis as the Pdx and DRG 196, reimbursement is $ 12186 with an SOI and ROM of 4 and 4.

With the alternate Pdx of aspiration pneumonia and DRG 177, reimbursement is $14558 (about $2400 more) but the SOI and ROM are only 3 and 3. Of course this is a mortality case!! Both palliative care and the DNR status are coded.

Do we go for SOI/ROM since the pt died, or reimbursement?

What would you recommend as the Pdx/DRG??

Thank you in advance for any thoughts!

Jillian Lightfoot RN
Clinical Documentation Team
Marshall Medical Center
Placerville, CA 95667
(530) 626-2770 Ext. 6203
jlightfoot@marshallmedical.org

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    If you are concerned about your O:E ratio, this is based off ALL patients so while I certainly try to optimize all death records (I review all ours), the SOI/ROM is not technically more important in this case than others (at least this is my understanding). Obviously we do not know the particulars of the case but my gut response is that pulm fibrosis is chronic and Asp PNA is the acute condition and likely more closely meets criteria for Pdx. With the information you have provided, I would go for that.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Asp PNA is acute and fibrosis is not: seems entirely logical to state focus of w/u and care would be towards the PNA rather than chronic fibrosis? So, PDX - Asp Pna.

    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

    evanspx@sutterhealth.org



  • ddouthitddouthit
    edited April 2016
    Based on documentation below. The following observations:
    Principal DX is defined as Condition after study that necessitated the admission. Pulmonary fibrosis is a chronic condition. Was the focus of treatment on the Aspiration PNA (the acute illness) or on pulmonary fibrosis (chronic) condition? I question whether both asp. Pna and pulmonary fibrosis meet guideline criteria for "two or more conditions present on admit both meeting criteria for principal diagnosis".

    Dorie Douthit RHIT,CCS
    AHIMA-Approved ICD-10-CM/PCS Trainer
    ddouthit@stmarysathens.org



  • jlightfoot@marshallmedical.orgjlightfoot@marshallmedical.org
    edited April 2016
    Thank you Katie. I always appreciate any information.

    On a side note, we have several "frequent flyers" with ongoing, progressive pulmonary fibrosis and have had several heated discussions about that diagnosis as a Pdx, it typically reflects greater SOI which leads to significant increase in reimbursement especially on our Medi-Cal pt's; our coders have been reluctant to use as the Pdx also stating that it is a chronic condition with no code to reflect an acute exacerbation.

    That said I was very surprised to see it used as the Pdx in this case especially since we had another respiratory condition. The coder based her decision on the palliative care note stating that the pt was being placed on comfort care for end stage pulmonary fibrosis.

    Our physicians will occasionally document "exacerbation" or "progressive severe" or "end stage"-does anyone have any input on using pulmonary fibrosis as the Pdx under these circumstances?

    Jillian Lightfoot RN
    Clinical Documentation Team
    Marshall Medical Center
    Placerville, CA 95667
    (530) 626-2770 Ext. 6203
    jlightfoot@marshallmedical.org




  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    As the chronic condition is described as stable and the patient was admitted with an acute condition - PNA - the PDX = PNA. This would be the case unless the documented circumstances of the admission, diagnostic w/u and/or therapy contradict the logic.

    See Guidelines Below:


    Effective October 1, 2011



    Narrative changes appear in bold text

    Items underlined have been moved within the guidelines since October 1, 2010



    Section II. Selection of Principal Diagnosis



    C. Two or more diagnoses that equally meet the definition for principal diagnosis

    In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.



    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

    evanspx@sutterhealth.org




  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Even in the scenario of an 'exacerbation' or 'end stage' you probably generally have another acute condition. Respiratory failure?

    But if there really was nothing else, then I would go with the fibrosis.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


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