Narcotic Overdose and Sepsis POA
A patient presented to ER with AMS. The patient was noted to have two Fentanyl patches on chest, one 25mcg and one 50 mcg. According to husband, the patient was only prescribed 25mcg patches and reported patient's MD had been decreasing the patient's patches. However, the family was unaware that the patient was doubling her patches. Patches were discontinued. In ER, the patient was given Narcan with some response (more alertness documented), transferred to the unit to continue Narcan infusion and observation. The patient was dx with Encephalopathy due to Narcotic overdose/overmedicated with continue Narcan in the H&P.
Narcan infusion was discontinued however, the patient continued with the Encephalopathy and MD documented patient with the dx of possible Sepsis, UTI, and Encephalopathy was likely due to the infection in PN in sequential documentation in the PN.
The patient was discharged. MD did not mention anything in Discharge summary of the Narcotic overdose on admission. I placed a query for Narcotic overdose ruled in or ruled out noted in the H&P. Since this would be considered a poisoning due to the wrong dose of medication.
The coder and I have MM due to fact that I coded the Narcotic overdose as Pdx since that is what the patient presented with and occasioned the admission to the hospital. However, the coder is coding the Sepsis as Pdx since this what the MD indicated was likely the cause of the Encephalopathy after study.
Do we ignore the Narcotic overdose and the Narcan treatment? My thought is this patient may have been septic on admission, but this is not what occasioned the admission to the hospital and if the patient was dx with a Narcotic overdose and Sepsis on admission, we would code the complication (T) code as Pdx (due to the poisoning) due to the OCG related to the complication of surgery and other medical care. (ICD-10-CM OCG FY 2019 page 108 of 120).
Any thoughts would be greatly appreciated...
Narcan infusion was discontinued however, the patient continued with the Encephalopathy and MD documented patient with the dx of possible Sepsis, UTI, and Encephalopathy was likely due to the infection in PN in sequential documentation in the PN.
The patient was discharged. MD did not mention anything in Discharge summary of the Narcotic overdose on admission. I placed a query for Narcotic overdose ruled in or ruled out noted in the H&P. Since this would be considered a poisoning due to the wrong dose of medication.
The coder and I have MM due to fact that I coded the Narcotic overdose as Pdx since that is what the patient presented with and occasioned the admission to the hospital. However, the coder is coding the Sepsis as Pdx since this what the MD indicated was likely the cause of the Encephalopathy after study.
Do we ignore the Narcotic overdose and the Narcan treatment? My thought is this patient may have been septic on admission, but this is not what occasioned the admission to the hospital and if the patient was dx with a Narcotic overdose and Sepsis on admission, we would code the complication (T) code as Pdx (due to the poisoning) due to the OCG related to the complication of surgery and other medical care. (ICD-10-CM OCG FY 2019 page 108 of 120).
Any thoughts would be greatly appreciated...
Comments
This one could go either way. The provider documented a clear cause of the encephalopathy in the H&P then reverses it in the PN. It's pretty clear the encephalopathy was the reason for admission the question is what was the true cause (and thus the pdx). You have conflicting information documented so you need to clarify it with a query.
If you have freeform queries I'd recommend a new query asking this:
Patient admitted with encephalopathy. H&P documents due to narcotic overdose/overmedication. Subsequent progress notes document possibly due to sepsis/uti. For proper assignment of a primary diagnosis please indicate which of the below is correct.
A. Encephalopathy caused by narcotic overdose.
B. Encephalopathy caused by sepsis/uti.
C. Encephalopathy multifactorial caused by both narcotic overdose and sepsis/uti.
D. Encephalopathy cause undetermined.
E. Other (please specify).
With an answer you'd know:
A = Narcotic overdose is pdx
B = Sepsis is pdx
C = Pick either one
D = Encephalopathy is pdx
E = Something totally different
A query like this could be confusing so being able to talk to the provider and explain it to him/her would be invaluable. As it stands now though you've got conflicting documentation in the chart.
Erik Kilbo, CCDS, CDIP, CCS, CPC-I
Manager - Enterprise HIM Coding
Greenville Health System