DVT vs PE as principal dx

Unknown

BC/BS is denying a case where the coder had a final diagnosis of DVT not
PE. Pt came in to the ER with left calf pain for 6 days and sporadic
chestpain...the Chief complaint documented by physician was left calf
pain and was admitted on Lovenox and Coumadin. A CT of the chest was
also performed to rule out a PE, this came back positive. Which pdx
would be appropriate?



Thanks,

Patti



Patti Stewart BSN,RN

Clinical Documentation Specialist

Mercy Medical Center

1301 15th Ave. West

Williston, ND 58801

pattistewart@catholichealth.net

cseluke

Offhand, I would think PE. Would the patient have been admitted for the
DVT alone? Was PE documented in the record other than on the CT report?



Cathy Seluke, RN, BSN, ACM, CCDS

Supervisor Clinical Documentation Compliance

MaineGeneral Medical Center

149 North Street

Waterville, ME 04901

Phone (207) 872-1796

Fax (207) 872-1519

Cathy.Seluke@mainegeneral.org

paxneros

You get a higher weight w/the PE as the MCC. If they were both acute on admission and treated equally...

NBrunson, RHIA, CCDS

digardsk

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I would likely go to the PE as DVT is sometimes treated on outpatient
basis, and the PE the more urgent condition. Kim

Unknown

I would have coded the PE. This is the more serious condition. The coding
rule states when two condition present on admission it is okay to choose the
most severe condition if both conditions are treated equally. The lovenox
and coumadin are treatments for the same. If the physician ordered the
chest CT on admission, but it was not done until the second day, I may would
have queried for present on admission. We always clarify present on admission
on all diagnoses not documented within the first 24 hours--unless the
diagnostic test was done on the day of admission.


In a message dated 3/29/2011 5:13:52 P.M. Eastern Daylight Time,
cdi_talk@hcprotalk.com writes:

I would likely go to the PE as DVT is sometimes treated on outpatient
basis, and the PE the more urgent condition. Kim

Unknown

In the ER documentation there was no indication of chest pain etc, and
no dx of PE made. The attending admitted this patient and he performed
the CT which showed the bilateral PE's when this was coded, the DVT with
PE as an MCC is higher weight. So the coder went with the DVT. Is this
not correct?

Unknown

This patient was clearly admitted with the DVT prior to the CT being
completed. Confused on what to do..

Patti

Unknown

The pt was clearly admitted with only the DVT diagnosis, as the CT was
not completed until after admission to the medical floor. They were
both treated equally with the same medications, so I am having a hard
time with this one.



Thanks,

Patti

Unknown

Good Morning Folks, not to belabor the DVT vs Pulmonary Embolism conundrum here but consider the following. Rather than focusing upon the DRG and sequencing of the diagnosis to allow for the capture of a MCC, let's take a step back and focus upon the true role of clinical documentation improvement, affecting positive change in physician's general patterns of clinical documentation throughout the record in support of the various elements that the record serves to capture and represent. These include as we are fully aware medical necessity, risk of morbidity and mortality, severity of illness reporting, risk of readmission within 30 days ( something vitally important with Medicare's Readmission Reduction Project as part of Value Based Purchasing Program, to name a few.

 

With this in mind, our role as CDIS in this particular instance is to review the record, evaluate the severity of signs and symptoms as evidenced in the ER, management in the ER, patient's Chief Complaint, recorded History of Present Illness in H & P, tests ordered and their results, and lastly the physician's provisional diagnoses and associated plan of care for each of these diagnoses. Using our clinical knowledge and results of our literature search if necessary, then and only then can we formulate in our minds what the principal diagnosis or diagnoses may be. As the physician continues to manage the patient's clinical conditions, executing his/her clinical judgment and medical decision making, we follow the patient's course of care and solidify the physician's recording of his/her evaluation and management through review of charting in the progress note. At this gesture, we can certainly discuss the case with the physician if the patient's clinical course is not well explained in the record. Certainly we can educate the physician on the importance and merits of complete and consistent clinical documentation throughout the record since this impacts the physician's ability to compliantly code and bill for the E & M services associated with the care of the patient. I like to remind physicians that they are paid under a Fee-for-Service model, they provide the service and it is up to them to chart appropriately so they can be paid for their fee.

 

In this particular case, which diagnosis is clinically supported as the principal diagnosis, taken into account the discussion above. Employing this rationale, the MS-DRG will be what it is and the associated reimbursement will be what it, keeping the MCC out of the equation. Our role as CDIS is to capitalize upon the opportunity to use our clinical knowledge in educating the coder in these very instances where the coder may have sequenced a principal diagnosis incorrectly, relying on the

trusty encoder "analyzer" as opposed to the clinical circumstances of the case.

 

At last,  what is the principal diagnosis in this clinical scenario?

 

Speaking of literature search, I subscribe to epocrates.com, a one stop shop for quick research on different clinical disease entities. They have a free trial subscription and I encourage anyone who is interested to register. I find this service to be extremely valuable for those time we want to be sure of the clinical justification and merits of a query.

 

cseluke

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