Hyponatremia Query Clinical Indicators

When training in my early CDI days, I was told that I could query for hyponatremia with two low NA values as clinical indicators as it shows that it is being monitored (not necessarily being treated). Discussions recently with one of our group veterans discredited this approach. I know all about pseudo-hyponatremia with hyperglycemia and would never query for hyponatremia with a markedly elevated glucose. My question is if I had a NA - 130 yesterday, & a NA - 128 today (both with glucose WNL), would these clinical findings in & of themselves qualify as valid clinical indicators to query for hyponatremia.


  • My personal guideline, Query should be based on at least two indicators (the two labs would be one indicator, i.e. lab value) as a query based on one indicator would typically be a red flag or at least a weak justification for a query (I am sure there may be exceptions...). In the past, this was reinforced by a well known CDI physician in a communication I had with him. So unless you can add more evidence (more than two labs?) as to what would justify the query, I would not query.

  • Monitoring is treatment. An additional indicator could be monitoring of GCS as hyponatremia is risk factor for injury to the CNS due to cerebral edema. Hyponatremia is also a diagnosis that impacts the SOI and ROM for a patient and this monitoring is quality care with a plan to treat if deemed necessary based on lab values and change in neuro exam. If no treatment is needed that is great news for the patient and the clinician provided the quality of care to support the patient, In my perspective.

    All that said I am also very familiar with defensive coding, audits, and a difference of perspective at the bedside vs final coding and billing:) May the documentation be with you!

  • Agree that monitoring without ‘active intervention’ can justify a query. Monitoring of a significant clinical event can demonstrate ‘medical-decsion-making’ process on part of the clinical team. Per UHDDS, a condition that requires ‘clinical evaluation’ may be eligible for reporting.

    What is ‘clinical evaluation”? The medical staff is aware of the condition and is evaluating it in terms of evaluation, testing, consultation and clinical observation of the patient’s condition and/or the existence of the condition affected the types or choices of treatment rendered to the patient

    Noting on the H&P that I have a bunion does not mean a bunion is coded; but, noting that I have CKD 4 means I have a significant condition that affects my treatment in terms of issues such as selection of antibiotics, fluid balance. The CKD 4 may not be ‘directly treated ‘in a patient with PNA, but if it is something the medical definitely is managing and taking into account in terms of how the patient may be treated (one example: ‘Renal Dosing” in a patient with aspiration pneumonia or carefully monitoring my CKD after contrast with a left heart cath).

    The same can be said for hyponatremia as stated above or something as significant as herniation of the brain in a patient admitted with ICH and immediately placed on Comfort Care. The hernia of the brain was a dire consequence of the ICH, and the fact it was not aggressively treated by choice does not make it ‘less re

    Paul Evans, RHIA, CCDS

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