Denial - recommend resequencing

annnd2009@gmail.com

Patient had a witnessed arrest by EMS. had called for dyspnea. patient arrived to ED intubated.

The insurer says  cardiac arrest should be principal because "likely Respiratory cause" wasn't stated as such in DC Summary - no one debates the PNA poa or the respiratory failure POA in the DC summary. Nor do they debate the sepsis POA that would have to lead if PNA were PDX

troponin elevated slightly to meet and has a type 2 MI coded. echo was normal ( they did not suspect cardiac cause)

h&p-OOH cardiac arrest, witnessed-Likely secondary to her respiratory failure.... severe sepsis poa, copd pan, LL PNA POA, acute COPD exacerbation POA...

dc summary  includes "Dc “

PEA and started ACLS with CPR. She was intubated and brought to *** after return of circulation. After evaluation she was found to have left pneumonia with parapneumonic effusion and a chest tube was placed. Her urine legionella was positive and her antibiotics were re-adjusted to reflect this. She was diagnosed with septic shock and was requiring pressors...

1. Acute on Chronic Hypoxemic/Hypercapnic Respiratory Failure

2. Out of Hospital Cardiac Arrest 3. COPD Exacerbation 4. Community Acquired Legionella Pneumonia 5. Severe Sepsis 2° to #4 6. Rapid Atrial Fibrillation  

the recommendation was for principal to be cardiac arrest , Type 2 MI drove.

not sepsis as coded, not acute respiratory failure, not pna.

question- would you have felt it needed to be queried?

would you have felt the need to query after the discharge summary- stated " PEA... found to have PNA with septic shock" for a cause?

vparent@emhs.org

It appears from your notes above, that the pt was not transported to your facility until after return of spontaneous circulation, thereby negating the out of hospital arrest as principle. Personally I would have gone with the sepsis as principle. The H&P documents arrest "likely" secondary to respiratory failure, likely diagnoses would need to be documented in the discharge summary for coding (that is the only query I see). The respiratory failure was likely caused by the COPD AE and PNA which leads me to use the sepsis as the principal.

The coding clinic below states cardiac arrest should not be sequenced as the principal if the underlying condition is known. I have also attached a link to another reference.
Cardiac arrest without underlying condition

      ICD-9-CM Coding Clinic, First Quarter 2013 Page:10 Effective with discharges: March 27, 2013

https://www.californiahia.org/sites/californiahia.org/files/docs/CDQarticles/2016-nov-dec-cardiac-arrest-vs-acute-respiratory-failure-update.pdf

I do not have my current CDI pocket guide with me but the 2017 version states:

"Cardiac arrest in unlikely to be principal diagnosis when the patient is resuscitated and survives to be admitted. If the cause if known, such as myocardial infarction, the cause would be sequenced first. If the cause, such as ventricular fibrillation, was corrected prior to admission, it would not typically be the focus of the admission pursuant to OCG II.B and C (circumstances of admission, therapy provided). Likewise, cardiac arrest with unknown or undocumented cause would rarely be the focus of admission. 
Often the consequences of cardiac arrest are the reason for admission and the most likely principal diagnosis. For example, a patient in cardiac arrest is resuscitated in the emergency room and admitted with respiratory failure (on a ventilator or not); respiratory failure would almost invariably be principal diagnosis as the focus of admission."