Dilutional Hyponatremia

dbeiseldenton

Would like to see what other CDI's and/or coders think?

Clinical Story: Patient admitted for 2 days. On last day, patients
labs are reviewed by resident and he makes note of Na 134 - dilutional hyponatremia-monitor. Patient was discharged that day.

Should the coder have reported the hyponatremia as a CC?
Should the coder have queried for clinical significance?
Should it have been denied by the payor?

Coders Rationale: It was documented, I don't need to query. I don't second guess the doctor. I don't know if it is significant or not. It was documented, I code it.

Auditors Rationale: It does not qualify as a secondary condition or CC because it was not treated, even though the resident made the diagnosis and wrote to monitor the Na, no further testing or monitoring was done because the patient was discharged that afternoon. The drop of 1 point of normal is not significant.

What are your thoughts? What would you do?

Thanks everyone,

catladyrn

I personally don't think it meets any of the definitions of a secondary diagnosis. It didn't require clinical evaluation, therapeutic treatment, diagnostic procedures, or extend LOS or increase nursing care. In short, it was a random lab finding that the physician noted as the patient was on his way out the door. The physician said "monitor," but didn't order or address any type of monitoring. If the lab value had been there and the diagnosis had not been rendered, I would not have queried for the diagnosis because there was no evidence of any clinical significance to a one-point drop below normal and no physical findings or treatment, particularly when it's been attributed to dilution. I suppose you could ask for the clinical significance of the diagnosis but I can't imagine what the response should be.

Renee

Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System

arozhkovskaya

We would query a provider to state clinical significance of Sodium level of 134. Clinically hyponatremia is not supported, so we would have to clarify with doc.

Anna Rozhkovskaya, RHIT, CCS, CCS-P
Manager, Clinical Documentation Improvement
Memorial Healthcare System
Health Information Management Department
2990 Executive Way, Miramar, Fl 33025
(954)276-9957 Office
(954)265-6974 Mobile 
(954)441-9459 Fax

evanspx@sutterhealth.org

Robert Hodges recently provided an excellent article speaking to the clinical significance of various levels of hyponatremia.

Having said that, the fact this is stated as 'dilutional' makes rationale to code rather weak, in my view, even w/ the statement it was followed with further testing. (Was this testing part of a BMP that would have ordered as normal workflow or protocol, or was further testing done specifically to follow the sodium level of 134?


As a previous responder stated, I'd at least query in order to confirm the clinical significance; would not code this w/o better justification. Personally, I really can't find a way to justify coding a level of 134 that is stated as 2/2 dilution.


Reference:

Guidelines for Achieving a Compliant Query Practice (2013) AHIMA/ACDIS Best Practice





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

jriley

We would definitely query. Contextually it doesn't sound significant, particularly with the use of the term "dilutional," but the provider would need to make that call.

Judy

Judy Riley, RHIT, CCS, CPC
AHIMA-Approved ICD-10/PCS Trainer
Coding/CDI Manager
LRGHealthcare
Lakes x 3315