DRG 982 - OR Procedure unrelated to the principal dx

k.bloodsworth@smmctx.org

I have a patient who was scheduled for an ORIF of the humerus for a fracture. Postoperative, the patient was lethargic and admitted to observation overnight. The patient was also hypoxic and the next day advanced to inpatient status.

What should the principal dx be? Humerus fx or hypoxia?

lsipos@monument.health

It should be the "reason for inpatient admission" from SSO to inpt...how about querying for POSTOP pulmonary Insufficiency? Though there is likely a coding clinic that says you will bill the procedure on that as well.....
WHAT bought the bed? What was the reason for INPT admission...

Juli

evanspx@sutterhealth.org

Juli cites correct logic....the 'rule' for PDX selection when a pt status is changed from "OBS" to "full (acute) admission" is the condition that necessitated the change in status.

My 1st question would be: "Does your site actually place ORIF pt in observation status initially? Don't these meet medical necessity to qualify as a regular (acute) admission?




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

katysuegood@gmail.com

I am with Paul. If the procedure was initially an OBS/OP procedure and then was changed to IP because of a complication (Hypoxia) then the complication should be Pdx. But our ORIF's are generally IP procedures as far as I know. You may want to clarify with UR as to whether this was intended to be an OP procedure or was there some sort of error with patient status.

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

Unknown

Folks - please, please, please - don't ever go for Post-op pulmonary insufficiency. There is no such condition in medicine since the 1850's when respiratory failure was called pulmonary insufficiency by some writers. First of all, it is unmeasurable, second it's irreproducible, thirdly it has no definition, fourthly it is a complication of surgery. If the patient was hypoxic with inability to maintain adequate oxygenation because of oversedation or lack of clearing the anesthetic agents from the system, look at this a possible adverse effect of anesthesia agents. Does the patient have chronic respiratory failure going into surgery and is there a diagnosis that made respiratory function marginal in the reversal process? Does the patient have a neuromuscular disorder that made it tough to adequately use muscles of respiration? Is there a metabolic process that prevented adequate detoxifying of narcotics used? If the patient was in respiratory failure, call it. Anything but postoperative pulmonary insufficiency. Puh-leeze!

Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)

lsipos@monument.health

Dr. Gold

I am going to forward this to our Consultant Group as they have been advising us to query for this for the last several years.....

Thanks!

Juli

Unknown

Bless you.

Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)

lsipos@monument.health

Dr. Gold

Can you help me understand...as I said we have been educated for years by our consultant group to query for this... and according to 3M, I can get code j952 as "acute pulmonary insufficiency following non thoracic surgery" ....(cc)

OR

If I go the different route, and a patient has post op hypoxia I can get codes j9589 (other post procedural complications and disorders of resp system not elsewhere classified), and hypoxemia R0902. (cc)

I am not an advanced practice provider, so often rely on clinical indicators, resource consumption and education from others.... so can you please explain why either of the above diagnoses couldn’t or wouldn’t be coded dependent on the situation? I AM USING extra resources for this....

Juli

amkelly3@partners.org

HI all,
Keep in mind that Respiratory Failure following non thoracic surgery on elective admissions is a PSI.
I would stay away from it.
In I-9 Acute pulmonary insufficiency following trauma or surgery would get you the MCC and keep you out of PSI territory.
We are still trying to sort this out for I10.

Andrea M. Kelly RN, JD, MSN

Program Director
BWFH Clinical Documentation Improvement

Interim Nursing Director
Ambulatory OB-GYN

(617) 774-8366 (c)


857-307-1105 (f)


amk

chj102060

It will not be a PSI if it is the principal diagnosis.
Is this a Medicare patient?
If so, due to the 72 hour rule the two stays should be combined and this
would not be an issue.

On Wed, Jan 20, 2016 at 11:25 AM, CDI Talk wrote:

lsipos@monument.health

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, January 20, 2016 11:55 AM
To: Bovard, Juli
Subject: Re: [cdi_talk] DRG 982 - OR Procedure unrelated to the principal dx

It will not be a PSI if it is the principal diagnosis.
Is this a Medicare patient?
If so, due to the 72 hour rule the two stays should be combined and this would not be an issue.

On Wed, Jan 20, 2016 at 11:25 AM, CDI Talk wrote:
HI all,
Keep in mind that Respiratory Failure following non thoracic surgery on elective admissions is a PSI.
I would stay away from it.
In I-9 Acute pulmonary insufficiency following trauma or surgery would get you the MCC and keep you out of PSI territory.
We are still trying to sort this out for I10.

Andrea M. Kelly RN, JD, MSN

Program Director
BWFH Clinical Documentation Improvement

Interim Nursing Director
Ambulatory OB-GYN

(617) 774-8366 (c)


857-307-1105 (f)


amk

evanspx@sutterhealth.org

I’d avoid coding this condition unless abundantly clear it is appropriate to do so. As someone stated, this condition may result in a Sole MCC for a stable pt admitted for a planned MV procedure or a CABG. Reporting this code will result in a POA of “N” in a pt that may not even have any documented risk factors for respiratory ‘insufficiency’, such as known and pre-existing cardiopulmonary disease (COPD, ILS, CM, CHF). So in essence, our data might show a high MCC capture rate for many patients undergoing a planned CV procedure – we know these pts are often a planned admission, and that they are ‘tuned up’ for the procedure. Improper coding could then indicate our surgical procedures result in a form of respiratory failure in a patient that only had something such as known MV prolapse. If one review only the coded date, the question would be “how/why are patients experiencing respiratory failure – particular those that have no other significant risk factor?

As another wrinkle, consider that CMS issued guidance that a ‘coder’ should consider a query for a condition, if said conditions is not supported.

Respiratory Failure, Postoperative
Background

The Diagnosis of Acute Respiratory Failure may be noted ‘routinely’ for patients that are on Mechanical Ventilation during the immediate recovery period. This may present an issue for CDI and Coding Teams as ‘ordinarily’, clinical statements documented by clinicians are accepted and coding without question.

2013 ACDIS/AHIMA guidance titled “Guidelines for Achieving a Compliant Query Practice” states “generation of a query should be considered when health record documentation ... provides a diagnosis without underlying clinical validation.” In addition, the brief states:

“The focus of external audits has expanded in recent years to include clinical validation review. … When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in
The health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.”

MLN Volume 1, issue 4, July 2011, Published by CMS – Advises a Coder to Query the MD for Acute Respiratory Failure that is clearly stated on multiple occasions.



An 81-year-old female was admitted with complaints of dry cough for a couple of weeks. The patient was admitted through the emergency department and was assessed for wheezing and coughing. H&P impression is acute respiratory failure secondary to exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Progress notes through the stay also document the diagnosis of acute respiratory failure secondary to exacerbation of COPD. Final diagnosis on the discharge summary is acute respiratory failure secondary to COPD exacerbation. Additional documentation sheet supplied in the record list the patient's diagnoses as: Principal Diagnosis: COPD exacerbation; Other Diagnoses: high blood pressure, Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Diabetes Mellitus (DM), Parkinson's, and rheumatoid arthritis.

Auditor finding: After physician and auditor review, it was determined that the clinical evidence in the medical record did not support respiratory failure, despite physician documentation of the condition.

Action: The auditor deleted acute respiratory failure and changed the principal diagnosis to COPD Exacerbation. The auditor deleted respiratory failure code 518.81 and changed the principal diagnosis to hypoxemia code 799.02. This resulted in a MS-DRG change from 189 to 192–Chronic Obstructive Pulmonary Disease without CC/MCC. This change resulted in an overpayment.

Guidance on How Providers Can Avoid These Problems:

✓ The condition chiefly responsible for a patient’s admission to the hospital should be sequenced as the principal diagnosis, and the other diagnoses identified should represent all CC/MCC present during the admission that affect the stay. Code only those conditions documented by the physician.

✓ Refer to the coding clinic guidelines and query the physician when clinical validation is required.



Extract from SWB Practice

Many physicians document “acute respiratory failure” in the postoperative period, even though it is usual and customary for the procedure. This may occur when patients are maintained on a ventilator following surgery even though it is a routine and expected aspect of the patients care inherent to the procedure performed. In other words, the “respiratory failure” is due to the procedure, falls within the routinely expected time frame, and does not require unusual resources, thus should not be considered a complication nor coded as an additional diagnosis.


It ‘may’ be appropriate to code if:

Ø Physician documents it as not routinely expected or as a complication of the procedure
Ø Physician documents as due to another cause or due to medications or anesthesia
Ø Mechanical Ventilation is required for more than 48 hours after surgery or reintubation with mechanical ventilation is performed

Respiratory failure is a relatively common postoperative complication that often requires mechanical ventilation for more than 48 hours after surgery or reintubation with mechanical ventilation after postoperative extubation. Risk factors may be specific to the patient's general health, location of the incision in relation to the diaphragm, or the type of anesthesia used for surgery. Trauma to the chest can lead to inadequate gas exchange causing problems with levels of oxygen and carbon dioxide. Respiratory failure results when oxygen levels in the bloodstream become too low (hypoxemia), and/or carbon dioxide is too high (hypercapnia), causing damage to tissues and organs, or when there is poor movement of air in and out of the lungs. In all cases, respiratory failure is treated with oxygen and treatment of the underlying cause of the failure. Source: AHA Coding Clinic• for ICD-9-CM, 4Q 2011, Volume 28, Number 4, Pages 123-125
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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

evanspx@sutterhealth.org

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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

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lsipos@monument.health

Thanks Paul.

Juli

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, January 20, 2016 12:49 PM
To: Bovard, Juli
Subject: RE: [cdi_talk] DRG 982 - OR Procedure unrelated to the principal dx

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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

vanessa.falkoff

Thank you Paul!

Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322

Compassion * Accountability * Respect * Integrity

evanspx@sutterhealth.org

Final thought: Cheryl Erickson posted an excellent ‘blog’ on this topic a few months ago at the ACDIS Home Page. I’d suggest that as a resource for anyone wishing to revisit this complicated issue.

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

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