Coding sequence for neoplasms - Need input please.

renmeyer@sbcglobal.net

Happy Friday everyone. I need some input please.  Patient came in to ER with SOB and generalized weakness.  She was recently admitted for pneumonia and dc'd with antibiotics.  She has bilateral nodules of her lung consistent of probable metastasis from (known) breast cancer.  Admission orders include abx empirically for possible pneumonia, O2, nebs and a pulmonary consult is scheduled.  Treatment during hospitalization includes lung CT scan, lung biopsy, bone scan, blood transfusions, pain management, IV antibiotics, steroids. CT guided lung biopsy reveals high-grade spindle cell neoplasm. Discharge diagnosis includes Pneumonia and Diffuse pulmonary metastatic disease with significant progression since admission with poor prognosis. 
Coder assigned Pneumonia as the PDX.  CDI thought the neoplasm should be the PDX as per CC 4th Q 2008 as well as CC 2nd Q 1990.  Coder disagreed and stated the pt was admitted because the pneumonia got worse, and that admission was for the treatment of pneumonia.

Any input would be greatly appreciated.
Thanks and Happy Friday!

Renee Meyer, RN, CCDS

Amy_Stremming_1992

I would agree with CDI since the thrust of the treatment/workup seems to be directed towards the pulmonary mets. I agree with the citing of both CC. The 1990 CC states:

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 guideline does not provide sequencing direction, any one of the diagnoses may be sequenced first.

In my opinion, the mets diagnostic workup/therapy outweighs that of the pneumonia (and pneumonia can often be treated as outpatient), so I agree with your thoughts.

renmeyer@sbcglobal.net

Thanks Amy! Anyone else with some input or advise?  Thanks!

sbomm

Would it make any difference in the situation above, if one diagnosis paid higher then the other? Would you use the higher paying dx as principle dx?

renmeyer@sbcglobal.net

The coder used the lower paying DRG. 

Amy_Stremming_1992

It sounds like the coder does not understand the physiology and treatment of the lung mets which can be very similar to pneumonia treatment. Perhaps if the pulmonary consult and subsequent biopsy were proven to be for work-up of the mets, this would allow the coder to see that the mets really were the focus of treatment.

jozog@cayugamed.org

Even though the pneumonia may have been what "bought the bed," the metastasis was present on admission (even though not known), She was at high risk for it with a history of breast cancer, diagnostic testing proving it, pneumonia (common in patients with lung mets), and she was treated for it. After careful study, thrust of care was with the diagnosis of metastatic lung CA.

renmeyer@sbcglobal.net

Thanks for the replies!  I appreciate the input!

Amy_Stremming_1992

Wonderful advice! That is best practice, then the coder, CDI, and doctor will all be on the same page.