Principal diagnosis selection
Can anyone give feedback and when to use prematurity as Principal diagnosis? What scenarios should you be reporting prematurity as Pdx? Our NICU will sometimes get transfers from an OSH for an extreme premature baby that another NICU has been caring for...The baby will present to us for "feeding problems". However will have a many problems going on upon arrival which all stem back to the extreme prematurity.
Another questions is selection of respiratory failure as pdx. We get alot of patients with RSV bronchiolitis, status asthmaticus, pneumonias/aspiration pna. Generally we will sequence the above diagnoses as Pdx and use the acute respiratory failure as secondary. We just got a new coding manager at our facility and she wants to use respiratory failure as Pdx in these situations. I'm looking for any insight on these matters.
Thank you for your time
JS
Another questions is selection of respiratory failure as pdx. We get alot of patients with RSV bronchiolitis, status asthmaticus, pneumonias/aspiration pna. Generally we will sequence the above diagnoses as Pdx and use the acute respiratory failure as secondary. We just got a new coding manager at our facility and she wants to use respiratory failure as Pdx in these situations. I'm looking for any insight on these matters.
Thank you for your time
JS
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Hi @spitlerj@childrensdayton.org ,
I have been currently going back and forth with some coders on these neonates that have been transferring from outside hospitals as to the PDX. I purchased the HCpro CDI pediatric essentials and the module on neonatal transfers states you can use the prematurity code if the reason for transfer the RDS, respiratory failure is due to or directly linked to the prematurity. So if I have a 26 weeker that was transferred to us with RDS, BPD, and other dx related to the extreme prematurity I have been making my PDX the extreme prematurity. I have also noted even when they make the PDX the RDS the APR DRG is still the Extreme Immaturity. I will go back later today and double check that, but I am pretty sure. If not I will come back and edit. lol I see this post is a few years old and I am curious to see what you have done and/or come up with since May of 2019?
As far as the respiratory failure as the PDX in the second question you posed, I have been noting this trend as well lately. When I first started in CDI it was just normally common place to have Respiratory Failure as the secondary dx. Unless, it was a diagnosis that normally could have been treated OP and the respiratory failure was the true reason for the admission and the complete focus of care. Status Asthmaticus is not something that can be treated OP. It requires inpatient admission with IV steroids , continuous cardiopulmonary monitoring, q1-2 hour nebs, possible 1 hour continuous neb in the ED, bipap, possible intubation, etc. So, I really believe the Status Asthmaticus would be what "bought the bed" and the respiratory failure is a secondary dx. As opposed to a child with RSV/bronchiolitis who failed OP treatment and has hypoxia, requiring supplemental o2, and increased treatment and monitoring. I can see a case for the respiratory failure being the PDX/leading with this.
I am curious to know your thoughts on my line of thinking.
Thanks in advance.
Shannon M. DiSilvestro (Sifuentes) BSN,RN, CCDS
Clinical Documentation Specialist
The University of Chicago Medicine
5841 S. Maryland Ave. | Rm. W-020, B-04 | Chicago, IL
Office: 773-702-4074
Mobile: 773-571-3629
Shannon.DiSilvestro@uchicagomedicine.org
Hi Jorde and Shannon,
Love this thread. I too struggle mightily with the NICU babies who are transferred in and past the 28day mark. It seems to depend on the circumstances before the transfer and then the rationale for the transfer but so often in our case, it's a transfer out from us and back again so on the return, the reasons for readmission are pretty lightweight.
On respiratory failure, I find the guidelines to make things more confusing than clarifying as they leave the PDX up to a subjective process:
"Acute respiratory failure as principal diagnosis:
A code from subcategory J96.0, Acute respiratory failure, or subcategory
J96.2, Acute and chronic respiratory failure, may be assigned as a
principal diagnosis when it is the condition established after study to be
chiefly responsible for occasioning the admission to the hospital, and the
selection is supported by the Alphabetic Index and Tabular List.
However, chapter- specific coding guidelines (such as obstetrics,
poisoning, HIV, newborn) that provide sequencing direction take
precedence."
My coding team also likes to apply this more uniformly as making a case for which of the two conditions- both of which were treated and POA, was truly the POA without a specific statement in documentation to indicate it presents a problem. We tend to default to the broader principle of what optimizes the DRG. However, as you mention here, I think this guideline would indicate there is a deeper thought process involved. We haven't figured out how to operationalize that process case by case.
Making it more complicated is the fact that if you use the principle I mentioned to determine the PDX, then a different PDX would apply based on the grouper. I know this is true of other things as well but makes this even more murky.
Hi Amy,
I tried to reach out to the email you left me and it was sent back. I can be contacted at Shannon.DiSilvestro @uchicagomedicine.org
There is no right answer or coding clinic that clearly states whether you should put the underlying acute condition (pneumonia, asthma, bronchiolitis, etc...) as principal vs acute resp failure as principal (as long as they met criteria for acute resp failure)
They both can be considered equally responsible for the admission in many cases. And when that happens, you should be sequencing in a way that provides for the highest relative weight.
you don't have to always put acute resp failure first or bronchiolitis first. Figure out which combo of principal vs secondary gets you the highest relative weight and sequence it that way. Depending on the SOI and DRG, sometimes resp failure principal gets you a higher relative weight and sometimes PNA/bronchiolitis/asthma do.
There are coding and other references related to this topic on this ACDIS post: https://acdis.org/articles/qa-two-principal-diagnoses