AMI sequencing
I'm in need of a reference for AMI sequencing. I was told when I began as a CDIS almost 5 years ago that when a patient is admitted with many diagnosis and AMI was one of the diagnoses, AMI is to always be the principle diagnosis. I have looked in coding clinic and coding guidelines but am not having success in fidging the reference. I'm probably overlooking it.
Do you know where I might find the reference.
Do you know where I might find the reference.
Comments
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Cathy Seluke, RN
Care Management
Phone: (207) 872-1796
Pager: (207) 823-0717
Whenever a patient is admitted with a PDx that indexes to MDC 5, Circulatory and an AMI (initial episode of care) is diagnosed at any time during the same encounter (admission), the PDx will be 1) that condition after study to have occasioned the admission), BUT the AMI will determine the final DRG.
Example:
PDx: DVT (or arrhythmia, CHF, endocarditis, for example)- (POA)
SDx: AMI (not POA)
DRG: 282 AMI w/out CC/MCC
If the AMI gets the "power" to drive/determine the DRG it can't also act as the MCC, which it ordinarily would, given it's MCC designation
But - consider the following:
PDx: Atrial fib (for sure, no evidence of MI at admission)
SDx: ESRD
SDX: AMI
DRG: 280 AMI w/MCC
So if the MI occurs or is diagnosed after admission (and clearly no MI symptoms on admit) then it will not become the PDx and take the place of the original PDx. Only the final DRG will change.
Further example:
PDx: Stroke (POA)
SDx: AMI (not POA)
DRG: 064 Acute cerebral infarction w/MCC
In summary, this rule only applies to any other PDx in Circulatory.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Charlene
facility with a 'sequencing choice', either may be used as the PDX with
result either will be an MCC.
(Perhaps you are thinking of some other rule pertaining to SIRS/Sepsis
sequencing, for instance, if pt with an infection, such as PNA, is
admitted with SIRS due PNA, then SIRS/Sepsis MUST be the PDX?)
However, if pt with 'significant' non-infectious condition, such as CVA
or AMI is also septic, then may be compliant coding and sequencing
choices...it depends.
Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
According to coding guidelines, whenever sepsis meets the criteria as principal dx it is always coded first. If sepsisand MI both meet the criteria for principal dx, sepsis still would be principal. The only time sepsis is not a principaldx is if it was not present on admission.
Thank you,
Angie Mckee, RHIT, CCDS, CCS, CCS-P
Clinical Documentation Specialist
Performance Improvement
University Health Care System
Augusta, Ga. 30901
706-774-7836
sepsis meets the criteria as PDX it MUST always be coded first". This
is not the case - cite the rule, please. There is no rule state Sepsis
'must' be the PDX when a patient is also admitted with another condition
that may be unrelated to infection/sepsis, such as severe MI with
Cardiogenic shock, for instance, or a devastating hemorrhage of the
brain with severe consequences.
Guidelines state:
Sepsis/SIRS with Localized Infection
"If the reason for admission is both sepsis, severe sepsis, or SIRS and
a localized infection, such as pneumonia or cellulitis, a code for the
systemic infection (038.xx, 112.5, etc) should be assigned first, then
code 995.91 or 995.92, followed by the code for the localized infection.
If the patient is admitted with a localized infection, such as
pneumonia, and sepsis/SIRS doesn't develop until after admission, see
guideline I.C.1.b.2.b)."
END OF QUOTE:
These guidelines apply if/when pt admitted solely for infection, such as
PNA, with SIRS/Sepsis.
However, if pt is admitted with Sepsis due to infection as well as ICH
with brain death due to hernia, in a coma and other documentation of a
catastrophic Brain event NOT due to Sepsis, a coding choice is
feasible. Admittedly, not very common, but we have had multiple admits
here for 'severe MI with cardiogenic shock, Sepsis due to PNA, and
severe ICH with brain edema.
REFERENCE:
C. Two or more diagnoses that equally meet the definition for principal
diagnosis
In the unusual instance when two or more diagnoses equally meet the
criteria for principal diagnosis as determined by the circumstances of
admission, diagnostic
workup and/or therapy provided, and the Alphabetic Index, Tabular List,
or another coding guidelines does not provide sequencing direction, any
one of the diagnoses may be sequenced first.
Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
I agree with your thinking. I was going to post the same, but you did it much better than I.
Kari L. Eskens, RHIA
BryanLGH Medical Center
Coding & Clinical Documentation Manager
patient level of morbidity and coding complexity. We have patients
admitted fitting the scenario below on a regular basis - unfortunately
and as you can imagine, I can't recall that any of them have survived.
Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
Thank you,
Angie Mckee, RHIT, CCDS, CCS, CCS-P
Clinical Documentation Specialist
Performance Improvement
University Health Care System
Augusta, Ga. 30901
706-774-7836
sepsis meets the criteria as PD it is ALWAYS coded first' - there are
exceptions and sequencing can be complicated and sophisticated -
selection of PDX can be 'hard' and requires in-depth analysis. I took
care to explain my rationale carefully.
Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
The closest I found is in DRG Expert - DRG 280 - above the list of ICD-9 codes, "Principal or Secondary Diagnosis".
Renee, if you are out there, what reference did you use to get so smart??? Or if anyone else has a suggestion would sure appreciate it.
Thank you,
Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com
PS: I believe you can find Renee's article on the ACDIS website if interested.
STEMI with PCI DES (drug eluting stent).
MS-DRG should be 247 (w/o MCC), correct?
The procedure should trump the AMI DRG 282 (w/o CC or MCC); just want to confirm.
Robert Kopec, MD, CPE, CCDS
robert.kopec@baycare.org