How to choose PDx from co-existing diagnoses

loretta.hoffmeister@samcstl.org

Can someone give some insight on how to decide which to choose between two co-existing diagnosis on admission.
We have some difference of opinion between CDI and Coding and would appreciate any input.
Scenario: Patient arrives in respiratory distress, RR 30-402, O2 sats 86% ra, cxr shows pulmonary vascular congestion, BNP elevated, treated with BIPAP, IV Lasix, admitted to ICU.

Would you use the Acute respiratory failure as Principal Dx -OR- Acute CHF as Principal Dx? What is your rationale?
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Unknown

From what I have understood is choose the diagnosis which was most invasive/most intense treatment. That being said when you have two diagnoses which meet the definition for PDx our coders choose the higher paying one. This almost always puts respiratory failure as a SDx.

From ICD-9 Coding Guidelines:



Section II. Selection of Principal Diagnosis

The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.

Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc).

In determining principal diagnosis the coding conventions in the ICD-9-CM, Volumes I and II take precedence over these official coding guidelines.

(See Section I.A., Conventions for the ICD-9-CM)ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2011 Page 89 of 107



The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.

A. Codes for symptoms, signs, and ill-defined conditions

Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are not to be used as principal diagnosis when a related definitive diagnosis has been established.

B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis

When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

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.

D. Two or more comparative or contrasting conditions.

In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

Charlene Thiry

loretta.hoffmeister@samcstl.org

When I took the CDI Bootcamp Training it was strongly indicated that you should choose the condition which is the main focus of treatment at the time of admission. Per our CDI teams review the patient came in for immediate treatment of the Acute Respiratory failure. The ED immediately made O2 adjustments increased NC, then mask and eventually placing on BIPAP, pt was also given IV Lasix. It just seems that the focus was on the respiratory failure at the time of admission. ICU would not routinely be required for a CHF Exacerbation, but should be for acute respiratory failure.

If a patient arrived in mild respiratory distress, O2 sat 89% on ra, placed on 3L, sats up to 95%, IV Lasix given, moved to Telemetry or Stepdown - then it would make more sense to me to choose the CHF as the PDx

Our coders routinely choose the CHF as PDx in these cases (due to higher weight) and I just wanted to make sure that we should not be questioning it more.

Thank you for the information you forwarded!!

evanspx@sutterhealth.org

I have read from several various sources seeming to indicate that an ‘acute exacerbation of CHF’ tends not to meet medical necessity for inpatient admission, with a further opinion stated that ‘CHF’ exacerbations routinely fall into Observation status?



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: 415.412.9421

evanspx@sutterhealth.org

julie.cruz-sje

Ditto on much of what everyone is saying. We also heard at the ICD-10 Boot camp to consider the Acute Respiratory Failure, not just in terms of resources utilized, but also in consideration of trying to reduce the incidences of 30 day re-admit for CHF.

Julie Cruz RN, CDS

Clinical Documentation Specialist
St. Joseph Health
2700 Dolbeer St
Eureka, CA 95501
wk: 707-445-8121 ext. 7550
cell: 707-267-0973

rmhosler1

Great point.