Clinical Validation
I recently sent a clinical validation query to an attending regarding pancytopenia.
The attending stated "pancytopenenia-secondary to cancer and associated treatment, monitor CBC, transfused platelets for paracentesis".
Patient with known pancreatic cancer. Noted to have pancytopenia on previous admissions. Lowest WBC this admission 4.4 with ANC of 4100. Pancytopenia was not stated by consulting oncologist.
I was directed to withdraw the query and coder told to code the diagnosis as "the physician documented his rationale".
My thoughts are that the query is justified, and this diagnosis would never withstand an audit.
I'm curious to know other views/opinions.
Comments
Hi Tracy, Adding some input on this one. Pancytopenia can always be a tricky condition for CDI and coding. You are correct to query as the WBC is not meeting the typical values of WBC < 4 and ANC < 1800. When we look for support on this condition, we normally look at the lab values first, then the etiology, and treatment. Basically, we are looking to get our "MEAT" or the support for Other diagnosis based on UHDDS. In this case, you have the attending giving you the diagnosis, the etiology, and then provides the treatment and monitoring. Now I do not know what all the labs reflected but remember not all patients are the same, and per coding guidelines we must report what is stated by the provider. You can also break up the pancytopenia and query for the anemia and thrombocytopenia as separate conditions if WBC's do not fully support. Since coding does not support your query, I would move this situation to one of education and discussion with your provider and look for future improvements. You can also reach out to your denials team to obtain data on this condition and see what the results have been for support of your queries. For education, ask the provider(s) what values and clinical indicators they consider pancytopenia. This eliminates frustration with all parties and allows you to educate on what is required for clinical support as well as specificity for coding (etiology). I will say, at least your providers are documenting pancytopenia as most do not! Hope that helps a bit.