"Versus" diagnosis preceded by a symptom

Lynn.heinrich@va.gov

Physician identifies "Falls likely multifactorial with contributions from infectious etiology (exudative pleural effusion vs complicated UTI) vs metabolic encephalopathy vs nutritional deficiency vs dementia".  Obviously a query is in order, but if the doctor doesn't further specify, how is this coded and why?  Thanks in advance!

afrady@blr.com

The guideline for Vs followed by possible causes was eliminated with the introduction of ICD 10.  Current advice now suggests coding all possible diagnoses listed and letting the circumstances of admission govern the selection of pdx.  

Just to nitpick. "Fall" is not a medical diagnosis. (neither is "jump", "sat down" or "cheered" by the way).  It is  patient event.   I have few questions.
1) What was the etiology of the exudative pleural effusion?  Cancer?  Abscess? Pneumonia? etc.
2) What makes this UTI "complicated" vs "simple". Is their anti microbial resistance?  Hemmorrhagic cystitis?  Pyelonephritis?  Obstruction?  Hydrocephalus?  What?
3) What is the nutritional deficiency?  Is it FTT? Mild malnutrition?  Is the patient simply cachexic or under weight?
4) What type of dementia?  Simple?  Vascular?  Alzheimers? etc.

The documentation you have currently would have been out of date and unacceptable 20 years ago, not just by today's standards.  

evanspx@sutterhealth.org

Agree w/ Allen;  This is what a coder would call a ‘chart from Hades’...the chart fails to list with any confidence the ‘chief’ reason determined after admission to have caused the admission.  If I had to code it, I’d not be able to do so and would submit a query for the principal diagnosis; after perhaps a  check of the CM notes in order to determine if it met criteria for adult admission, ideally, ask a physician supportive of CDI to review the chart and discuss w/ the Attending.