pulmonary edema, ESRD compliant with HD, CHF

littlebit_62703@yahoo.com

Hello,

 I have a case where the patient has ESRD compliant with HD,  hypertension, ischemic cardiomyopathy with CHF came in for shortness of breathe and cough found to have mild pulmonary edema stat HD was ordered for the next day , hypertension uncontrolled,. no documentation of fluid overload chest xray shows edema and cardiac enlargement and no documentation of acuity level for pulmonary edema. Would you query on this for acuity and etiology based on this documentation and I think there is also a coding clinic similar to this situation? The facility I am auditing states that the etiology is already documented linking this to the ESRD since the MD states "stat Hemodialysis"  was ordered. I disagree and recommend the coder to query but they insist that the physician is already making the link. What are your thoughts? 

Thanks,

kim_ogle@comcast.net

Based on the information provided further cause and effect clarification is warranted by the provider. One can not assume a cause and effect relationship.between the  patients presenting symptomolgy, abnormal CXR findings, the acuity level, comorbidities and HD treatment.. without futher documented link from the provider. The patient maybe HD compliant but may not be compliant with his/her p.o. fluid restrictions.

evanspx@sutterhealth.org

If you have access, it may be helpful to read:

Be patient with me...this is very obtuse.

Coding Clinic,  1st quarter,  2016

Coding Clinic, 1st Quarter  2014

The issue is that the terms Fluid Overload,  CHF, and Pulmonary need to be very carefully cited in the record in order that the proper codes are applied.  If an ESRD patient is stated to have 'fluid overload' with CHF,  the fluid overload is considered to be a symptom of the CHF

 Pulmonary Edema 'with' CHF is coded to CHF, unless the record explicitly states something such as "Non-Cardiogenic Acute Pulmonary Edema". 

If a pt with ESRD presents w/ fluid overload due to noncompliance with dialysis, fluid overload might be the PDX, IF:

Pt has no H/O CHF or evidence of CHF

OR

Record states the fluid overload was not cardiogenic or that the CHF is not decompensated.

It would be important to ask the following:

  Non-Cardiogenic Fluid Overload due to?

  Non-Cardiogenic Acute Pulmonary Edema due to?

P. Evans, RHIA

evanspx@sutterhealth.org

littlebit_62703@yahoo.com said:

Hello,

 I have a case where the patient has ESRD compliant with HD,  hypertension, ischemic cardiomyopathy with CHF came in for shortness of breathe and cough found to have mild pulmonary edema stat HD was ordered for the next day , hypertension uncontrolled,. no documentation of fluid overload chest xray shows edema and cardiac enlargement and no documentation of acuity level for pulmonary edema. Would you query on this for acuity and etiology based on this documentation and I think there is also a coding clinic similar to this situation? The facility I am auditing states that the etiology is already documented linking this to the ESRD since the MD states "stat Hemodialysis"  was ordered. I disagree and recommend the coder to query but they insist that the physician is already making the link. What are your thoughts? 

Thanks,

In the scenario described above, the PDX would be:

Hypertensive Heart and Renal Disease:

 followed by the ESRD and the CHF.

Pulmonary edema is integral to the CHF, unless explicitly stated as not associated with any CHF, and then should be stated as Non-Cardiogenic Acute Pulmonary Edema.

Coding classification assumes hypertension as cause of hypertensive CHF and ESRD.   If you wish to do so,  you would query for acuity and type of CHF in order to gain specificity. 

Ref:  Coding Guidelines and Coding Clinics provided earlier.

You did not state how the facility coded this case?

Paul Evans, RHIA, CCDS

evanspx@sutterhealth.org

Assume the CHF is stated as systolic, no other specification

I13.2  Hypertensive CKD with CHF

I50.20,  Systolic CHF, NOS

N18.6  ESRD

z992.  Dialysis Status

evanspx@sutterhealth.org

Clarification.  For purpose of illustrating potential codes,  ASSUME the type of CHF is documented as systolic.   Did not mean to imply assumption of systolic CHF.

paul_evans_90314 said:

Assume the CHF is stated as systolic, no other specification

I13.2  Hypertensive CKD with CHF

I50.20,  Systolic CHF, NOS

N18.6  ESRD

z992.  Dialysis Status

littlebit_62703@yahoo.com

Thank you for your help on this. Unfortunately, the facility does not agree with me or my recommendations and they decided to code the PDX to J81.1 chronic pulmonary edema and secondary dx of I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease. There response back to me was that they disagree because "we already know the pulmonary edema is non cardiogenic “stat HD this morning for pulmonary edema". That means it is renal etiology not cardiac, which makes it non cardiogenic. and Acute pulm edema or pulm edema NOS does not change the DRG as the PDX. " 

evanspx@sutterhealth.org

Thanks for sharing more information.  IMO, you are correct to question the coding for this case.

I can state I disagree with the codes selected by the site.  Pulmonary edema with CHF is coded to CHF rather than pulmonary 'unless' the record is very clear the pulmonary edema is NOT cardiogenic.  

Further,  I'd question how or why a site would use  Chronic Pulmonary Edema as the 'chief reason' found after study to have caused an admission to an acute care site.   (How does this meet clinical criteria, such as Interqual, McKesson, satisfying admission criteria)?

The statement cited' stat HD for pulmonary edema' in a patient with known CHF is coded to CHF.   I could find a cite more references for you, but my time is limited.   This is one of the more complicated CDI/Coding issues, in my view. 

Best,  Paul

bbogda@morrishospital.org

 I wish there was just a 'thumbs up' button you could click when you just want to show agreement for a post without sending an update out to everyone.   I agree with Paul.  :

littlebit_62703@yahoo.com

Thank you. I have been instructed by my superiors to let the facility code how they want and not go any further with this but thank you anyways. Next Thursday is my last day with the company i work for and i will be moving on to a new position and a new company. Thank you so much for all your help though. I am happy that we have these forums to discuss things of this nature. 

theresekeating925@gmail.com

I have a scenario following the same lines as above, however the patient was in obs status until they went into acute rest failure do pulm edema and required input admission to icu followed by intubation.  The question has arisen if the acute respiratory failure is the pox since it occasioned the inpatient admission.  Thoughts?

evanspx@sutterhealth.org

If the patient is admitted as an inpatient for observation the principal diagnosis is the condition which led to the change in status...in this case, the acute respiratory failure.

2018  Official Coding Guidelines

Admission Following Medical Observation When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission.