COPD/pneumonia

Unknown

A pt comes in with both COPD exac and pneumonia, POA. I sequence COPD w/MCC vs Pneumonia w/CC. For some reason, the coders I am working with now say pneumonia has to go first. One coder said she will 'consider' COPD w/MCC but only if the pt receives SoluMedrol. I contend it would be the exception for any physician to definitely say one diagnosis was causing the dyspnea over the other.

Am I missing something here? Is there a coding rule/clinic I am unaware of???????

Thanks a million, always appreciate the good advice I get from CDI-Talk

Linnea Thennes, RN, BS, CCDS
Clinical Documentation Specialist
Centegra Hospital - McHenry
815.759-8193
lthennes@centegra.com


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Unknown

This is the only coding clinic I can find. It does not inlcude COPD exacerbation.

In the end, the coder is the one who is held responsible for the record.

Which diagnosis received the most intense treatment? If the PN was treated with IV antibiotics and the COPD with respiratory treatments (no IV SoluMedrol) then perhaps the PN would be PDx?

laura.jansen

Here is a more recent coding clinic.

Exacerbation of COPD with Pneumonia
Coding Clinic 1st Quarter, 2010, p12

Question:
When a patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and an infection such as pneumonia, is pneumonia always sequenced as the principal diagnosis?


Answer:
Sequence either code 486, Pneumonia, organism unspecified, or code 491.21, Obstructive chronic bronchitis, with (acute) exacerbation, as the principal diagnosis, when the patient is admitted with both conditions. The pneumonia and COPD are two separate conditions that presented simultaneously. The pneumonia is not the exacerbation of the COPD.

The Official Guidelines for Coding and Reporting previously published in Coding Clinic, Fourth Quarter 2008, page 303, states "In those rare instances 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 guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first."

dbutler

Something that can go either way here. What makes sense to me, and
seems to be a consensus, is to focus on the degree or intensity of
treatment and clinical condition. If COPD is treated with oral meds,
only a couple of resp tx before returning to home schedule, etc., it
just doesn't seem that the diagnosis of COPD meets the definition of pdx
-- it may not have required inpt care as a stand along dx. IV
solumedrol vs po steroids is one of the factors influencing the way the
choice goes.

I try to consistently look at the real and full clinical picture --
what is going on? what really needs the inpatient care? .... and then
worry about assignment of codes, pdx etc. if there remains room for
choices.

This specific question strongly involves the definition of a pdx (from
the ICD-9-CM Official Guidelines FY11):
“that condition established after study to be chiefly responsible for
occasioning the admission of the patient to the hospital for care.”

"When there are two or more interrelated conditions (such as diseases
in the same ICD-9-CM chapter or manifestations characteristically
associated with a certain disease) potentially meeting the definition of
principal diagnosis, either condition may be sequenced first, unless the
circumstances of the admission, the therapy provided, the Tabular List,
or the Alphabetic Index indicate otherwise."

Don

mahmed1

SoluMedrol is part of the exacerbation treatment, but not all the time. if physician writing COPD exacerbation that should be enough no matter how he treat the patient. some pneumonia is underline cause for exacerbation. as per coding guideline if symptom followed by both condition meeting primary diagnosis criteria, choose either one.

thanks,

Mohammad

Sincerely,

Mohammad Ahmed, M.D, CCS,
Clinical Documentation Specialist
Bronx Lebanon Hospital Center
Health Information Management
1650 Grand Concourse
Bronx, NY 10457
Phone: 718-518-5119
Fax: 718-518-5634
Email: mahmed1@bronxleb.org

kmckaig

We run into the same thing with our coders at times. I am not aware of
one. Our Director of Coding will override the DS if the coder "isn't
comfortable" with it.

I agree, appreciate the tips from everyone.
Karen


Karen McKaig, BSN, RN, CCM, CPUR
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org

robert.hodges2

Hmm, I wonder if insurance companies may be behind this. We had an audit recently where they wanted us to change pneumonia to the primary diagnosis too which means they would get a refund. We fought it with success saying both conditions were present on admission and were equally treated. We also asked them to produce a reference saying COPD had to go first and they couldn’t.



Robert



Robert S. Hodges, BSN, MSN, RN

Clinical Documentation Improvement Specialist

Aleda E. Lutz VAMC

Mail Code 136

1500 Weiss Street

Saginaw MI 48602



P: 989-497-2500 x13101

F: 989-321-4912

E: Robert.Hodges2@va.gov

bonnie.diehr

According to Coding Clinic below if a patient presents with conditions that are equally addressed during the stay you can sequence the higher weighted MS-DRG. Key is “equally treated.” According to our auditors if the patient is receiving IV Solu-Medrol, Nebs for COPD exacerbation and IV Antibiotics for the Pneumonia you can select the COPD as principal.



Principal diagnosis selection guidelines 10/1/2008

Coding Clinic, Fourth Quarter 2008 Page: 302 to 304 Effective with discharges: October 1, 2008 Related Information



Section II. Selection of Principal Diagnosis



The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."



C. Two or more diagnoses that equally meet the definition for principal diagnosis



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



© Copyright 1984-2010, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

dbutler

Agreed Robert -- the influence of the concern 'what will RAC say' does
seem to be having an affect in a variety of ways.

Only caveat for the CDI & coding community, must stress a portion of
your post Robert:
"were equally treated"

If not, may get ourselves into a bit more risk/trouble.

The one I've been seeing lately -- a particular diagnosis or condition
is very well & consistently documented, but not really supported
clinically. This really puts the coder in a bind -- guidelines require
reporting diagnosis documented, but it is pretty clear that the clinical
factors don't support the diagnosis. RAC/others reviewing will likely
successfully overturn.
One of the areas for CDI to be active -- capture complete and ACCURATE
medical record that is well supported with the clinical documentation
and scenario. Sometimes this does mean a lower reimbursement -- but it
is the RIGHT reimbursement.

Don