linking....

We recently had a recent topic come up with our CDI's and physician advisor and I am hoping to get some guidance on the issue.

The question came up when we were doing a group chart review on a record where the coder had asked for multiple retro queries.

The patient was admitted with PAD with limb ischemia with dry gangrene. Patient also had charcot foot with possible osteomyelitis. History of DM type 1, HTN, smoker. The chart had not been reviewed concurrently but the coder was requesting queries on:

1. Connection between the PAD and DM

2. Connection between Osteo and DM

3. Charcot arthropathy and DM.

What came up in this conversation is whether/how a CDI should query for connections between diseases when there may be multiple factors at play. For example, I have been under the impression that we should be routinely querying for the connection between osteo and DM. This was an area that has been referenced numerous times as a CDI opportunity in ICD-10 since the assumed relationship was removed in I-10. However, our PA feels like it is often very difficult to separate the multiple chronic conditions to determine a single cause. He felt this way about the PVD and the osteo.
I pulled up the Coding clinic Q12002p7 which suggest that when there in an underlying condition that is 'contributory' to another condition, this should not be coded as a causal relationship.

With this in mind, do you think it is inappropriate/leading to query for a causal link between 2 conditions when there may be multiple factors contributing to the illness or is this coding clinic really differentiating between 'contributory' and 'cause'. Is it possible to have multiple underlying conditions as a 'cause' rather than multiple conditions 'contributing to' a condition. I realize I am splitting hairs with the definitions of terms, but this really is where the conversation got hung up. For example, when we have PVD, DM, HTN, and Tobacco use in an 78 year old patient, is it appropriate to query for a causal relationship between DM and PVD when the HTN, age, smoking may also be contributing to the conditions as well? Are we 'picking and choosing' the links we are querying for? Also, if the provider documents that both the HTN and DM are causing the atherosclerosis, is it appropriate to code this as a diabetic complication?

I apologize if this question is confusing and appreciate your help.

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

Comments

  • Hi, Katy,

    DM and manifestations can be Complicated situation, and has been for decades, presenting considerable challenges for coding. If association is not clear, I feel one should query. I$B!G(Bd also read the most recent Coding Clinic for DM and any associated manifestation that is charted.


    Query Topic: Association

    An association between diagnoses may not be assumed and must be explicitly documented.

    On (DATE) documentation in the (NOTE TYPE) section of the medical record states***
    and
    on (DATE) documentation in the (NOTE TYPE) section of the medical record states***

    Please document the association, if any, between these conditions such as:
    Association exists
    No association


    You could also use something like the language below (I know portions are dated), and suit to your clinical situation.





    Request for Documentation Clarification - Diabetes Mellitus


    Dear MD/PA/NP: _____________________________ or other responsible provider:
    For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
    On____________documentation in the __________________________section of the record states:

    Please 1) describe the type of DM 2) state if there are any acute metabolic consequences and /or long-term complications. For your reference, some definitions are offered on the reverse of this form.
    Type of DM

    Diabetic Consequences

    Type 1
    Type 2
    Secondary$B"*(B Etiology: Indicate below:
    Post-Surgical
    Other: _______________

    Stress-Induced hyperglycemia w/o DM
    Cannot be Clinically Determined
    Disagree: No DM Present
    Other: ________________________


    Acute Metabolic Consequences
    No acute metabolic consequences at this time
    Acutely uncontrolled - etiology (note if a complication of surgery): ___________________________
    DKA - Blood Glucose> 300 with evidence of ketoacidosis (e.g. metabolic acidosis, + acetone)
    Hyperosmolarity - Blood Glucose > 600 w/o significant ketosis, usually with significant hypovolemia
    Diabetic Coma
    Other ______________________
    Cannot be clinically determined
    Chronic Complications
    No Chronic Complications
    Diabetic Nephropathy - list the stage of the Chronic Kidney Disease - ___________
    Diabetic Retinopathy
    Diabetic Neuropathy $B"*(BType: Radiculopathy Somatic Autonomic Other
    List Consequences, such as Gastroparesis Impotence Ulcer Other
    Diabetic vasculopathy - specify locations: __________________________
    Other Consequences - state: ____________________________________
    Cannot be clinically determined



    Control of DM

    Controlled
    Uncontrolled
    Other:
    Cannot be determined



    CDI Specialist/Coder: _________________________________ Date:_____________ Time: _______________

    Physician Printed Name:______________________________________________________________________

    Physician Signature: _____________________________________________Date: __________Time:_______


    Addressograph or patient sticker








    Definitions & Notes

    Source of Definitions: Goldman$B!G(Bs Cecil Medicine, 24th Edition


    * Type 1 Diabetes, formerly known as insulin-dependent diabetes mellitus or juvenile-onset diabetes (primarily due to $B&B(B-cell destruction, usually leading to absolute insulin deficiency)


    * Type 2 Diabetes, formerly known as non-insulin-dependent diabetes or adult-onset diabetes (may range from predominantly insulin resistance with relative insulin deficiency to predominantly secretory defect with insulin resistance)



    * Secondary Diabetes


    * Genetic defects of $B&B(B-cell function (e.g., maturity-onset diabetes of the young, types 1 to 9; point mutations in mitochondrial DNA)
    * Genetic defects in insulin action (e.g., type A insulin resistance, leprechaunism, Rabson-Mendenhall syndrome, lipoatrophic diabetes)
    * Disease of the exocrine pancreas (e.g., pancreatitis, trauma, pancreatectomy, neoplasia, cystic fibrosis, hemochromatosis, fibrocalculous pancreatopathy)
    * Endocrinopathies (e.g., acromegaly, Cushing's syndrome, hyperthyroidism, pheochromocytoma, glucagonoma, somatostatinoma, aldosteronoma)
    * Drug or chemical induced (e.g., vacor, pentamidine, nicotinic acid, glucocorticoids, thyroid hormone, diazoxide, $B&B(B-adrenergic agonists, thiazides, phenytoin, interferon-$B&A(B)
    * Infections (e.g., congenital rubella, cytomegalovirus)
    * Uncommon forms of immune-mediated diabetes (e.g., stiff man syndrome, anti-insulin receptor antibodies)
    * Other genetic syndromes (e.g., Down syndrome, Klinefelter's syndrome, Turner's syndrome, Wolfram's syndrome, Friedreich's ataxia, Huntington's disease, Laurence-Moon-Biedl syndrome, myotonic dystrophy, porphyria, Prader-Willi syndrome)



    Diagnostic Criteria for Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome
    CRITERION

    MILD DKA

    MODERATE DKA

    SEVERE DKA

    HHS

    Plasma glucose (mg/dL)

    >250

    >250

    >250

    >600

    Effective serum osmolality (mOsm/kg)*

    Variable

    Variable

    Variable

    >320

    Urine or serum ketones (NP reaction)

    Positive

    Positive

    Positive

    Negative to small

    Arterial pH

    7.25-7.30

    7.00-7.24

    7.30

    Serum bicarbonate (mEq/L)

    15-18

    10-15

    15

    Anion gap (mEq/L)

    >10

    >12

    >12

    Variable, usually
  • We have recently received denials on 3 cases where the patients had osteomyelitis and diabetes. The discharges were May and November 2014 and March 2015. We had coded osteomyelitis as principal diagnosis (on the advice of Coding Clinic Q4 2013 which unlinked diabetes and osteo in ICD 10). The cases are all coded in ICD 9, of course, since the I 10 implementation was delayed. Our lead coder wants me to appeal them on the basis of the 2013 Coding Clinic, but I interpret it as the two conditions were unlinked in ICD 10 only. Then of course they got relinked in Coding Clinic Q4 2016. Help!! My  head is exploding. 
  • Great question >Are we 'picking and choosing' the links we are querying for? Also, if the provider documents that both the HTN and DM are causing the atherosclerosis, is it appropriate to code this as a diabetic complication?

    I think the links are well established especially in your case:
     "PAD with limb ischemia with dry gangrene. Patient also had charcot foot with possible osteomyelitis. History of DM type 1,"

    Neuropathy (Sensory,Motor,& Autonomic) Ischemia (macrovascular, not microvascular,), and an abnormal immune response form a triad of underlying risk factors that contribute to diabetic foot infections. Unrecognized and untreated diabetic foot infections progressively spread to deeper layers ultimately resulting in limb-threatening abscesses or contiguous osteomyelitis.

    Regarding the Osteomyelitis (one fifth of Diabetic foot wounds) in your case :
    The presence of ischemia increases the risk of nonhealing making an invasive procedure such as a bone biopsy less appealing. If a bone biopsy is not available or contraindicated by ischemia, the diagnosis of osteomyelitis depends on surrogate markers including clinical, laboratory, and
    imaging findings.

    Reference:
    Kalish J, Hamdan A. Management of diabetic foot problems. J Vasc Surg. 2010;51(2):476–86.

    Lipsky BA. A report from the international consensus on diagnosing and treating the infected diabetic foot. Diabetes Metab Res Rev. 2004;20 Suppl 1:S68–77

    Hope this helps!
  • If the physician's documentation links a foot ulcer to a patient's diabetic peripheral vascular disease or diabetic neuropathy and the thrust of the treatment was toward the ulcer, what would the principal diagnosis?
  • We teach that even if the relationships are assumed, if there is any other possible etiology a query is needed. We need to clarify the story as accurate to the patient. 
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