Neoplasm/pericardial effusion coding

I have a patient with stage 4 lung cancer that presented with fatigue, cough, and loss of appetite. Initially they thought he had PNA but when they did an ECHO on day one they found a pericardial effusion (malignant). The initial report says no tamponade. The next say the patient had a cardiac arrest and given the pericardial effusion they did a bedside ECHO during resuscitation. This showed R atrial collapse and they did an emergent pericardiocentesis for pericardial tamponade. The patient was resuscitated but was deemed terminal and later died. No definitive treatment was directed at the lung cancer.

I am in discussion with coding and 2 issues have come up.

1. How to code the effusion. The coder thinks that it may be appropriate to only code C7989 (secondary malignant neoplasm) to code the malignant effusion. I don't feel this accurately captures the effusion and think that I39.3 (pleural effusion) should be coded.

2. Sequencing. She currently has C7989 as pdx. I am wondering if we code I39.3 whether this should be pdx. Sequencing guidelines say complications of neoplasm should be Pdx.

How would you code the effusion and what would your Pdx be?

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • edited May 2016
    Hi Katy,
    This is a tough one for me. I39.3 is not a valid code so I'm not sure what code you are recommending for the pdx.

    There is no specific code for malignant pericardial effusion so I can see how the coder came up with C7989. However, see following.

    J91.0 (Malig pleural effusion) is a manifestation code and cannot be sequenced as pdx. Underlying condition is to be sequenced first. Per NIH, malignant pericardial effusion is also a manifestation so I think the lung neoplasm might have to be the pdx - if that is the underlying cause.( Cardiac tamponade is not to be sequenced first as well.)

    It's Monday morning.... so I may be way off base here. Other's thoughts?

    [cid:image001.jpg@01D18368.E0D025B0]
    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


  • Ooops! I was curious about I313. Pericardial effusion. This is not specifically for malignant pericardial effusion but it was the closest thing I could find. We also have a pleural effusion coded because we had a pleural effusion too but I also saw that this was a manifestation code and could not be coded first. I guess you are right that if we did have a code specifically for the malignant pericardial effusion it would likely be a manifestation code as well. Of course the regular pericardial effusion code is not. I can see coding the pericardial effusion as a secondary site. However this doesn't really seem to capture the acuity?


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • Ahhhh!!! So you get to this code if we have documentation of an ‘acute’ pericardial effusion. We don’t have documentation of acute vs chronic. Query??

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • edited May 2016
    I would also code the cardiac tamponde (I31.4) which should demonstrate the acuity a little more clearly. I like I30.8 or .9 as suggested by Dr. G. I had missed that I30.x included acute pericardial effusion if it is specified as acute. Given his presentation (fatigue, cough,loss of appetite) though, it kind of sounds like lung Ca might maybe should be the pdx?


    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


  • Yes, I have the tamponade coded (POA-N) as well. Sharon, would you query for the acuity on the effusion? I agree about the presentation but if you think about 'after study' what occasioned the admission??? We didn't direct anything at the cancer???

    I appreciate your help

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • edited May 2016
    Katy- Yes, I would query for acuity and for underlying cause of effusion (primary, metastatic, other, undetermined. I think you need both queries to determine pdx. (Had big, long explanation of my reasoning in an email but I must have deleted it.)

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


  • Hahaha! No problem Sharon, I appreciate your help. They have clearly identified the effusion as malignant, so I think I am ok there. I will query for acuity.

    Thanks so much.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • Katy
    This is what I was referred in my long lost email regarding query for source of malignant pericardial effusion. Too bad I10 does not have a code for it. Lost some specifically in this case..

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, March 22, 2016 6:53 AM
    To: Salinas, Sharon
    Subject: RE:[cdi_talk] Neoplasm/pericardial effusion coding

    Malignant pericardial effusion
    Coding Clinic, Second Quarter 1989 Page: 12
    Effective with discharges: July 31, 1989
    Question:

    How is malignant pericardial effusion coded?

    Answer:

    The Alphabetical Index entry for Effusion, pericardium has a (see also Pericarditis) instruction that leads the coder to the following entry:


    Pericarditis - . - (with effusion)
    neoplastic (chronic) 423.8
    acute 420.90.


    The physician should be asked if, in this particular instance, the pericarditis is acute or chronic in nature. One of the causes of noninfectious pericarditis with effusion is a tumor, either a primary tumor (benign or malignant) of the pericardial site, or a tumor metastasizing to the pericardium (commonly carcinoma of the lung or breast and lymphomas).

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