PULMONARY EMBOLISM CONUNDRUM

matthewayinde@hirecdi.com

Hi All, 

Working on this chart in real-time I encountered this conundrum decided to share with my ACDIS mates. See question at the bottom of the page.

HPI from H&P

This Patient is 47 yrs. old Hispanic Female presents to ER with Cough, chest pain associated with the coughing, and Shortness of breath.  The patient stated that a cough is nonproductive and be present for the last 6 months but worse since yesterday. Since diagnosed with PE 6months ago and cough has not improved. 

NUCLEAR MEDICINE PERFUSION LUNG SCAN

IMPRESSION:
Patchy areas of decreased lung perfusion at both lung bases, corresponding to chronic infiltrates on chest x-ray. Lack of ventilation study results in decreased specificity and sensitivity or possible emboli. Findings suspicious for low to an indeterminate probability of PE.

Consultation:

Suggest to continue the patient on Lovenox and consider Eliquis for a low to intermediate probability of pulmonary embolism. Patient has a prior history of venous thromboembolism but does not want to undergo CT angiogram secondary to contrast allergy even after premedication. Inconclusive studies high risk for PE

Seem like the provider decided to threat as if the patient as PE because CTA cannot be performed. Would you query to clarify if PE is ruled in? or just consider treatment as prophylactic? or no query is needed will code PE? 

 Thank you 

jlprinz@att.net

Greatings - In this instance  could we clarify -based on treatment if this a "possible PE" -
This will capture as if it is in fact ruled in. Use the possible , probable , likely, in order to capture the empiric treatment.  

Thanks you -

bbogda@morrishospital.org

We would most likely code it as he states "continue the patient on Lovenox and consider Eliquis for a low to intermediate probability of pulmonary embolism."  Doesn't sound like he has ruled out anything and he is treating for it.

morris-jeff@CooperHealth.edu

jlprinz@att.net said:

Greatings - In this instance  could we clarify -based on treatment if this a "possible PE" -
This will capture as if it is in fact ruled in. Use the possible , probable , likely, in order to capture the empiric treatment.  

Thanks you -

I would do what this member says.

Thanks, Jeff

matthewayinde@hirecdi.com

Thank you for your responses.
I asked the same question internally, and I did receive a mixed response. So when in doubt you query right? So I sent the query and PE was ruled in. The provider also explained she couldn't rule out the condition and she would instead treat it than miss a PE diagnosis. 

RPinson@PinsonandTang.com

My impression is that this documentation of "possible pulmonary embolus" constitutes an "uncertain" diagnosis which should be coded as confirmed if "documented at the time of discharge" (whatever your interpretation of that statement is) and treatment is consistent with an established diagnosis of PE.

Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com

kay.piper

Reviving this thread...I'm seeking input on which of the following terms/phrases are ones that you or your facility consider to be terms of uncertainty. These are ones that Coding Clinic does NOT address but are frequently documented:

Almost certainly

Appears to be

Features of

May have

Presumed

Seems to be

Suspicious of

Thought to represent